First 5 minutes critical workflow
›Immediate stabilization
›Airway protection if unable to protect airway
›Cardiac monitor
›IV access
›Point of care glucose within minutes of arrival
›Immediate treatment targets
›Treat if glucose below 3.9 mmol/L with symptoms
›Treat if glucose below 3.0 mmol/L regardless of symptoms
›Repeat glucose in 10 to 15 minutes after therapy
›Immediate escalation
›If seizure or coma then IV dextrose immediately
›If refractory after two boluses then start dextrose infusion and ICU consideration
Glucose replacement therapy
›If awake and able to swallow
›Oral fast carbohydrate 15 g
›Recheck glucose at 15 minutes
›Repeat oral carbohydrate 15 g if still below 4.0 mmol/L
›Follow with complex carbohydrate and protein when stable
›If altered or unable to swallow with IV access
›Dextrose 10 percent IV 150 mL over 10 to 15 minutes
›Recheck glucose at 10 to 15 minutes
›Repeat dextrose 10 percent IV 150 mL if still low
›If recurrent then dextrose infusion 10 percent at 100 to 200 mL per hour titrate to glucose 6 to 10 mmol/L
›If no IV access
›Glucagon IM 1 mg
›Glucagon SC 1 mg
›Establish IV access as soon as possible
›Oral carbohydrate once awake and safe
Etiology directed therapy
›Sulfonylurea suspected or confirmed
›Octreotide 50 mcg SC
›Repeat octreotide 50 mcg SC every 6 hours as needed
›Dextrose bolus for immediate correction with octreotide for recurrence prevention
›Activated charcoal within 1 to 2 hours if protected airway and large ingestion
›Insulin overdose
›Prolonged dextrose infusion expectation
›Frequent glucose monitoring every 30 to 60 minutes once stable
›Potassium monitoring and repletion as needed
›Sepsis or critical illness
›Sepsis bundle local protocol dependent
›Early antibiotics when indicated
›Adrenal insufficiency suspected
›Hydrocortisone IV 100 mg if adrenal crisis concern
›Isotonic fluids for hypotension
Monitoring and reassessment loop
›Reassessment cadence
›Glucose every 15 minutes until above 4.0 mmol/L and stable
›Glucose every 30 to 60 minutes during observation
›Neuro status reassessment after normalization
›Treatment complications monitoring
›Extravasation risk with dextrose
›Fluid overload risk with infusion in heart failure
›Hypokalemia risk during insulin driven shifts
›Consultation triggers
›Toxicology for sulfonylurea or insulin overdose
›Endocrinology for recurrent unexplained hypoglycemia
›Obstetrics for pregnancy
›ICU for infusion requirement or refractory course