Hypoglycaemia and Hypoglycaemic Coma

Description

Emergency Treatment

Referral

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ICD-10 code: E10.0/E11.0/E12.0/E13.0/E14.0/E16.0/E16.1/E16.2

DESCRIPTION

Hypoglycaemia is a blood sugar < 3 mmol/L (< 2.6 mmol/L in neonate) and may rapidly cause irreversible brain damage and/or death.

Clinical features include:

• tremor
• confusion
• sweating
• delirium
• tachycardia
• coma
• dizziness
• convulsions
• hunger
• transient aphasia or speech disorders
• headache
• irritability
• impaired concentration

There may be few or no symptoms in the following situations:

• chronically low blood glucose
• patients with impaired autonomic nervous system response, e.g.
  • the elderly
  • malnourished
  • very ill
  • treatment with beta-blockers
  • those with long-standing diabetes mellitus

People at risk of hypoglycaemia:

• neonates with low birth weight or ill or not feeding well
• malnourished or sick children
• shocked, unconscious or convulsing patients
• alcohol binge
• liver disease
• diabetics on treatment

Hypoglycaemia may be a marker of deteriorating renal function.

EMERGENCY TREATMENT

• Obtain blood for glucose determination immediately.
• Establish blood glucose level with glucometers or testing strip.

Conscious patient, able to eat

Adult

• Sweets, sugar, glucose or milk by mouth.

OR

• Oral sugar solution
  • Dissolve 3 teaspoons of sugar (15 g) in a 200 mL cup of water.

Breastfeeding child

• Administer breast milk.

Older children

• A formula feed of 5 mL/kg.

OR

• Oral sugar solution
  • Dissolve 3 teaspoons of sugar (15 g) in a 200 mL cup of water – administer 5 mL/kg.

OR

• Sweets, sugar, glucose by mouth.

Conscious patient, not able to feed without danger of aspiration

Administer via nasogastric tube:

• Dextrose 10%, 5 mL/kg.
  (add 1 part 50% dextrose water to 4 parts water to make 10% solution)

OR

• Milk

OR                                                              

• Sugar solution.
  • Dissolve 3 teaspoons of sugar (15 g) in a 200 mL cup of water; administer 5 mL/kg.

Unconscious patient

Children

• Dextrose 10%, IV, 2–5 mL/kg.
  • 10% solution, e.g. add 1 part 50% dextrose water to 4 parts water for injection to make 10% solution.
  • After dextrose bolus, commence dextrose 5-10% infusion, 3-5 mL/kg/hour to prevent blood glucose dropping again.
  • Re-check the blood glucose after 15 minutes: if still low: give further bolus of dextrose 10%, IV, 2 mL/kg and continue dextrose infusion.
  • Feed the child as soon as conscious.
  • Investigate underlying cause e.g. infection.

Adults                                                                                                                                                                          

• Dextrose 10%, IV, 5 mL/kg immediately and reassess.
  • 10% solution, e.g.: 1 part 50% dextrose water to 4 parts water for injection to make 10% solution.
  • Generally, an immediate clinical response can be expected.
  • Maintain with 5% dextrose solution infusion until blood glucose is stabilised within the normal range.
  • Investigate underlying cause e.g. infection.

LoE:IIIb¹¹

Alcoholics/ malnourished (adults)

LoE:IIIb¹²

• Thiamine, IV/IM, 200 mg immediately.

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CAUTION
Thiamine should preferably be administered prior to intravenous glucose to prevent permanent neurological damage. Do not delay the dextrose administration in a hypoglycaemic patient.

Although potentially serious allergic adverse reactions may rarely occur during, or shortly after, parenteral administration, it is recommended that:
- This should not preclude the use of parenteral thiamine in patients where this route of administration is required, particularly in patients at risk of Wernicke-Korsakoff syndrome where treatment with thiamine is essential;
- Intravenous administration should be by infusion over 30 minutes;
- Facilities for treating anaphylaxis (including resuscitation facilities) should be available when parenteral thiamine is administered.

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LoE:IVb¹³

REFERRAL

Urgent

• All hypoglycaemic patients on oral hypoglycaemic agents.
• Hypoglycaemic patients who do not recover completely after treatment.
• All children who have had documented hypoglycaemia (unless the cause is clearly identified and safe management instituted to prevent recurrence).

Click here for the pdf.

Click here for the NEMLC Recommendations for medicine amendments (2020-4 review cycle).

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Standard Treatment Guidelines and Essential Medicines List for South Africa, Primary Healthcare, 2020-4_Version 1.1_October 2024

Chapter 21: Emergencies and Injuries