Hypoglycaemia (low blood glucose)

Potential medical emergency — brain cells start to die very quickly without glucose

• Happens when BGL low enough to cause symptoms and signs — can happen in people without diabetes
• Person with usually high BGL may have symptoms with normal BGL (eg 5–6mmol/L)
• Newborns very susceptible and high risk of complications
• Many causes — alcohol, glucose control medicines, aspirin, beta-blockers, insulin, sepsis, toxins
• All clinics should keep and maintain emergency low blood glucose kit
• Tubes of glucose gel or jelly beans or sugar sweetened cordial — not diet or lite
• Weetbix or dry biscuits/crackers
• Copy of this protocol

Do first — if person unconscious

• If BGL less than 4mmol/L  — treat straight away. Do not delay 
• If any chance person is a regular heavy drinker of alcohol or severely malnourished — give thiamine IM or IV — 100mg at same time or immediately after glucose
• If IV/intraosseous access — give glucose
• Child 10 years and under — 2mL/kg glucose 10% — bolus
  
• Child over 10 years or adult — 50mL glucose 50% (25g glucose) — slowly into a peripheral vein at a rate not greater than 3mL per minute
• If glucose 10% not available — dilute 1 part 50% glucose with 4 parts normal sterile saline for injection 
• If no IV/intraosseous access — give glucagon IM into the thigh, buttock or upper arm
  
• Child less than 25kg — 0.5mg (½ vial)
• Child 25kg or more or adult — 1mg (1 vial)
• If glucose or glucagon not available — put glucose gel or honey on  buccal mucosa (inside of cheek)
• Child and adult 15g of glucose gel or 3 teaspoons of honey (not recommended for children under the age of 5 years)
  
• Medical consult

Ask

• If on any medicines — have they taken their medicine, could they have taken someone else’s
• If child — could they have taken medicines or alcohol
• Have they eaten that day, what (any carbohydrate foods)
• Any vomiting and/or diarrhoea
• Unwell recently — sepsis, fever and chills, cough, urinary problems

Check

• If BGL less than 4mmol/L — treat
• Coma scale score 
• Do they have right medicines — check bottles/packets, dose aid
• Person is safe (eg seated securely and not at risk of falling)

Do

If person conscious but unable to eat or drink

• Medical consult as soon as possible but don't delay treatment
• Put 2 teaspoons honey in person's mouth or smear glucose paste on inside of person's cheek. May increase sugar level even if they can't swallow it
• Give glucagon IM 
• Child less 25kg — 0.5mg (½ vial)
• Child 25kg or more or adult — 1mg (1 vial)
• If glucagon not available OR no response to glucagon after 5 minutes — put in IV cannula and give
• Child under 10 years — 2mL/kg 10% glucose
• If 10% glucose not available — dilute 1 part 50% glucose with 4 parts normal sterile saline for injection
• Child 10 years and over and adult — 50mL 50% glucose — slowly into a peripheral vein at a rate not greater than 3mL per minute
• When improved
• If BGL less than 4mmol/L — give simple sugar/glucose
• If BGL 4mmol/L or more  — give long lasting carbohydrate

If person conscious and can eat and drink

• Medical consult as soon as possible, but don't delay treatment
• Give simple (fast-acting) sugar/glucose (equal to 15g carbohydrate)
  
• 5g for under 5 years
• 10g for 5–12 years
• 15g for over 12 years and adults
• Examples of 15g of fast-acting carbohydrates
• 200mL diluted cordial, 6 jelly beans, 60mL of 75g OGTT mix, 90mL of glucose drink, 2–3 teaspoons of sugar, 3 teaspoons of honey (not recommended for children under the 5 years)
• 15 rule — give 15g of carbohydrates, check BGL in 15 minutes and give another 15g of carbohydrates if BGL still low
• If BGL 4mmol/L or more — give long-lasting (slow-release) carbohydrate 
• Examples: 4 dry biscuits/crackers, 1½ Weetbix, 1–2 slices bread or damper, 1 piece of fruit, 1 cup of milk

Follow-up

• Check BGL again 30 minutes after last test
• If BGL less than 4mmol/L — repeat treatment
• Check BGL hourly — until BGL more than 5mmol/L on 2 tests in a row
• Will take longer to rise if
• Kidney failure, liver failure, sepsis not ruled out
• Taken blood glucose lowering medicine — takes long time to wear off
• If person goes home — someone must stay with them for next 4 hours. May have low blood glucose again. Carer needs to be able to recognise signs of low blood glucose, give simple sugar/glucose if needed
• Advise to have carbohydrates with each meal for next couple of days AND not to drive or operate machinery
• Medical follow-up if cause not known as further investigation needed
• Medical follow-up if person known to have diabetes
• Review medications
• Food intake
• Education with patient and family about hypoglycaemia