• Hypoglycaemia is the term used to describe low blood glucose levels. For patients with type 1 diabetes, hypoglycaemia is due to a relative excess of insulin over available glucose, resulting in a disturbance of glucose metabolism. There are both medical and lifestyle risk factors for hypoglycaemia

• The definition of hypoglycaemia is a blood glucose of <4.0 mmol/L for patients with diabetes. This should not be confused with the lower minimum level of <3.0mmol/L used for patients without diabetes.

• Correction of hypoglycaemia is a medical emergency. If left untreated, hypoglycaemia may lead to the patient suffering permanent brain damage and may even prove fatal.

• There are three classes of hypoglycaemia: mild, moderate and severe. In mild cases, the person can treat themselves, whereas in severe cases, third-party assistance will be required.

• Some patients can detect the early symptoms for themselves, but others may be too young or deteriorate rapidly and without apparent warning.

• Any person with a reduced level of consciousness, who is having a convulsion, is seriously ill or is traumatised should have hypoglycaemia excluded.

• Abnormal neurological features may occur, for example, unilateral weakness, similar to a stroke. Patients with symptoms indicative of a stroke should have an immediate blood glucose test to exclude hypoglycaemia.

• Signs and symptoms of hypoglycaemia can vary from person to person. Symptoms may be masked due to medication or other injuries, for example with beta-blocker medicines

• It should be noted that classic symptoms of hypoglycaemia may NOT always be present, and children may have a variety of unusual symptoms with low blood glucose

ASSESSMENT and MANAGEMENT of: Hypoglycaemia

Assess <C>ABCDE

• Start correcting <C>ABCDE problems

• Consider and look for medical alert/information signs (alert bracelets, chains and cards).

Assess Blood Glucose Level

• Measure and record blood glucose level (pre-treatment measure).

• Clean the patient’s fingers prior to testing blood glucose levels as they may have been in contact with sugary substances (e.g. sweets). It is vital that fingers are cleaned using a non-alcohol based wipe, or gauze with sterile water or sodium chloride, and dried thoroughly with a gauze swab prior to obtaining a blood glucose reading. Do NOT use alcohol-based wipes as these may give a false high reading.

Category in Hypoglycaemic Emergencies

Refer to Glycaemic Emergencies Algorithm: Click here

Severe

• Patient unconscious (GCS ≤8), convulsing or very agitated, or aggressive.

• Check <C>ABCDE and correct as necessary.

• Administer IV glucose 10%

• Only administer IM glucagon if IV glucose 10% is not possible. NB IM glucagon to be given ONCE ONLY .

• The onset time for glucagon is 10 minutes (but it can take up to 15 minutes to take effect). Glucagon requires the patient to have adequate glycogen stores so may be ineffective if they have been exhausted through frequent episodes of hypoglycaemia, alcohol use or low carbohydrate diet. Also, it is less effective in patients who take a sulphonylurea medicine (e.g. gliclazide, glipizide, tolbutamide, glimepiride), are chronically malnourished or take excess alcohol, so IV glucose 10% is preferred in these groups.

• Keep nil by mouth as there is an increased risk of aspiration/choking.

• Titrate IV Glucose 10% to effect – an improvement in clinical state and glucose level should be observed rapidly.

• Re assess blood glucose level after 5 minutes. If <4.0mmol/L, administer a further dose of IV glucose 10%.

• Re assess blood glucose level after a further 15 minutes.

• Consider rapid transfer to the nearest suitable receiving hospital if no improvement.

• Monitor vital signs and conscious level en-route. Check glucose again if patient deteriorates, or half-hourly.

• Provide a pre-alert/information call if necessary.

Mild to Moderate

• Patient conscious, orientated, and able to swallow.

• If capable, cooperative and deemed to have a safe swallow, administer 15–20 grams of quick-acting carbohydrate, such as one of the following:

• 150–200 ml pure fruit juice, e.g. orange (avoid pure fruit juice if a renal dialysis patient because of potassium content) or

• 1–2 tubes of 40% glucose gel or

• 3–4 heaped teaspoons of sugar dissolved in water (NB this is not an effective treatment for patients taking acarbose as it prevents the breakdown of sucrose to glucose).

• Do not give chocolate, as it is slower-acting.

• If NOT capable and cooperative, but able to swallow, administer 1–2 tubes of 40% glucose gel to the buccal mucosa or give IV glucose 10% or IM glucagon (refer to Glucagon) if IV access is not possible.

  • NB IM glucagon to be given ONCE ONLY.

• Re-assess blood glucose level after 10–15 minutes and ensure blood glucose level has improved to at least 4.0 mmol/L in addition to an improvement in level of consciousness.

• If no improvement, repeat oral treatment up to three times in total.

• If no improvement after three treatments or 30–45 minutes, give IV glucose 10% (refer to Glucose 10%).

Additional Information

• Once blood glucose is >4mmol/L, give a starchy snack, e.g. two biscuits, one slice of bread/toast, 200–300 ml glass of milk (not soya) or a normal meal if due (must contain carbohydrate).

NB Patients given glucagon require a larger portion of long-acting carbohydrate to replenish glycogen stores (double the suggested amount above).

NB Patients who self-manage their insulin pumps (CSII) may not need a long-acting carbohydrate.

• Transfer to the nearest suitable receiving hospital if the patient requires further treatment, otherwise the patient can usually be safely left at home. If the patient is a child, ensure they are left with a responsible adult.