Severe Hypoglycemia Management

Algorithm Steps

1. ▶

   Start

   Suspected Hypoglycemia

   Patient with symptoms or confirmed low glucose

   1. ◆

      Decision

      Classify Hypoglycemia Level

      ADA Classification

      • Level 1: Glucose 54-70 mg/dL (3.0-3.9 mmol/L) - Alert value
      • Level 2: Glucose <54 mg/dL (<3.0 mmol/L) - Clinically significant
      • Level 3: Severe - Altered mental status, requires assistance
      1. ◆

         Decision

         Is Patient Conscious & Able to Swallow?

         Assess mental status and ability to take PO

         1. ●

            Action

            Oral Glucose Treatment

            Rule of 15

            • Give 15-20g fast-acting carbohydrate:
            • - Glucose tablets (4 tabs = 16g)
            • - 4 oz (120 mL) juice or regular soda
            • - 1 tablespoon sugar or honey
            • Recheck glucose in 15 minutes
            • Repeat if still <70 mg/dL
            1. ●

               Action

               Recheck Glucose in 15 Minutes

               Assess response to treatment

               1. ◆

                  Decision

                  Glucose >70 mg/dL & Symptoms Resolved?

                  Evaluate treatment response

                  1. ●

                     Action

                     Post-Treatment Care

                     Prevent recurrence

                     • Give substantial snack or meal if not eating soon
                     • Include protein and complex carbohydrates
                     • Review cause of hypoglycemia
                     • Adjust diabetes medications if needed
                     • Education on hypoglycemia prevention
                     1. ●

                        Action

                        Evaluate Underlying Cause

                        Identify precipitant to prevent recurrence

                        • Missed meal or reduced food intake
                        • Excess insulin or secretagogue dose
                        • Increased physical activity
                        • Alcohol consumption
                        • Renal or hepatic impairment
                        • Adrenal insufficiency (consider if recurrent)
                        1. ✓

                           Outcome

                           Hypoglycemia Resolved

                           Ensure follow-up and medication adjustment

                        2. ⚠

                           Warning

                           Hospital Admission

                           For refractory, sulfonylurea, or unclear cause

                  2. ●

                     Action

                     Repeat Treatment

                     Glucose still low

                     • Repeat glucose treatment
                     • Consider continuous D10W infusion
                     • Evaluate for sulfonylurea or long-acting insulin
                     • May need prolonged monitoring (12-24h)
                  3. ⚠

                     Warning

                     ⚠️ Sulfonylurea Warning

                     Extended monitoring required

                     • Sulfonylurea-induced hypoglycemia may recur
                     • Monitor glucose every 1-2 hours for 12-24h
                     • Consider octreotide 50 mcg SubQ q6-8h
                     • Hospital admission often required
         2. ◆

            Decision

            IV Access Available?

            Determine route for treatment

            1. ●

               Action

               IV Dextrose

               Preferred if IV access present

               • D50W: 25-50 mL (12.5-25g dextrose) IV push
               • OR D10W: 100-250 mL if peripheral line
               • Effect within 1-3 minutes
               • May repeat in 15 minutes if needed
               • Follow with D10W infusion if recurrent
            2. ●

               Action

               Glucagon Administration

               When IV access not available

               • Intranasal: 3 mg single spray (preferred)
               • IM/SubQ: 1 mg injection
               • Auto-injector: Per device instructions
               • Onset: 10-15 minutes
               • Turn patient on side (aspiration risk)
               • Less effective if glycogen depleted