Hypoglycaemia In Diabetics
Diabetic Emergencies
ICD-10 Code: E10.0/E11.0/E12.0/E13.0/E14.0
DESCRIPTION
- Diabetic patients on therapy may experience hypoglycaemia for reasons such as intercurrent illness (e.g. diarrhoea); missed meals; inadvertent intramuscular injections of insulin or miscalculated doses of insulin or progressive renal failure leading to decreased insulin clearance; alcohol ingestion; and exercise without appropriate dietary preparation
- Risk factors include age <6 years of age, low HbA1c, and longer duration of diabetes
- Hypoglycaemia in diabetic patients can be graded according to the table below:
|
Mild/ moderate hypoglycaemia |
Severe hypoglycaemia |
|
|
|
|
*Except children <6 years of age
|
Autonomic symptoms/ signs |
Neurological symptoms/ signs |
|
|
Note:
- Children, particularly <6 years of age, generally are not capable of self- management and are reliant on supervision from an adult
- Patients may fail to recognise that they are hypoglycaemic when neuroglycopenia (impaired thinking, mood changes, irritability, dizziness, tiredness) occurs before autonomic activation
DIAGNOSIS
- Blood glucose <4mmol/L with symptoms in a known diabetic patient
- Blood glucose concentrations should be measured with a glucometer to confirm hypoglycaemia
Hypoglycaemia must be managed as an emergency.
If a diabetic patient presents with an altered level of consciousness and a glucometer is not available, treat as hypoglycaemia.
EMERGENCY TREATMENT
- Measure blood glucose concentration with glucometer/ testing strip, immediately
Conscious patient, able to feed
Breastfeeding child
- Give 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
Adults
- Sweets, sugar, glucose by mouth
OR
- Oral sugar solution
- Dissolve 3 teaspoons of sugar (15 g) in a 200 mL cup of water, administer 5 mL/kg
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 a 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
IV administration of dextrose in children with hypoglycaemia:
- Establish an IV line. Do not give excessive volumes of fluid: usually can keep line open with 2mL/kg/hour
- Take a blood sample for emergency investigations and blood glucose
- Check blood glucose
- If low, i.e. <2.5 mmol/L or if testing strips are not available, administer 2–5 mL/kg of 10% dextrose solution IV rapidly
- In the majority of cases an immediate clinical response can be expected
- Recheck the blood glucose after infusion
- If still low, repeat 2 mL/kg of 10% dextrose solution
- After recovery, maintain with 5–10% dextrose solution until blood glucose is stabilised
- Feed the child as soon as conscious
Adults
- Dextrose 10%, solution, IV, 2-5 mL/kg
- Do not give unless hypoglycaemic or hypoglycaemia strongly suspected
- Do not give excessive volumes of fluid
- If hypoglycaemia is treated:
- Re-check blood glucose 10–15 minutes later
- If still low, give further bolus of dextrose 10%, IV, 2 mL/kg, and commence dextrose 5 or 10%, infusion, 3–5 mL/kg/hour to prevent blood glucose dropping again
- Assess continuously until the patient shows signs of recovery
Alcoholics (or where alcohol intake cannot be excluded)
- Thiamine, IV/IM, 100mg immediately
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
REFERRAL
Urgent
- All hypoglycaemic patients on oral hypoglycaemic agents
- Hypoglycaemic patients who do not recover completely after treatment
- All children with documented hypoglycaemia unless the cause is clearly identified and safe management instituted to prevent recurrence
Standard Treatment Guidelines and Essential Medicines List for South Africa, Primary Healthcare Level, 2024 Edition