Hypoglycemic events: Can you leave them be?

By David Ismael Arbona Calderón, MD

Case Scenario: A 48-year-old unconscious male presented with dizziness and weakness in his office. On arrival of paramedics, patient is diaphoretic and unresponsive, but with pulse and spontaneous respirations. Initial assessment reveals a glucose level of 23 mg/dL. Paramedics find the patient’s current medication list in his wallet. Patient is given IV dextrose and regains consciousness. After returning to baseline the patient is refusing transport and further treatment. How do you proceed?

Literature Review: Diabetes is one of the most common chronic disease, with an estimated diagnosis of 23.1 million people in the United States and another 84.1 million adults with prediabetes [1]. As diabetes continues to increase in our population, hypoglycemic events are rising, secondary to the use of insulin and oral hypoglycemic agents. Insulin management has been related to the most serious cases of hypoglycemia, either due to strict goals of keeping normal glucose levels or due to confusion between dosing and type of insulin medication.

Other diabetes medications, like sulfonylureas, have been linked to episodes of hypoglycemia and accidental ingestion in the pediatric population. Although hypoglycemia is more common in Type 1 diabetes (T1DM), patients with type 2 diabetes (T2DM) experience a similar frequency of these events as they require more aggressive treatment.

The National Electronic Injury Surveillance System-Cooperative Adverse Drug Event Surveillance (NEISS-CADES) estimates around 97,648 ED visits occur annually due to insulin-related hypoglycemia and errors related to diabetes management. An estimated 10 percent of ED visits are considered Adverse Drug Events (ADEs) annually [2].

Around 95 percent of hypoglycemic events occur outside of medical settings, requiring assistance by family members, other caregivers or EMS personnel [3]. Patients with diabetes might not understand when hospital evaluation is needed for proper management of low blood sugars. EMS personnel carry most of the weight of identifying red flags of hypoglycemic episodes that require further workup, as some cases can be fatal.

There is a continuous debate in the ambulance service as to whether patients suffering from hypoglycemia need to be transported to the hospital after examination and treatment in the field [4]. While some studies have indicated that most cases of hypoglycemia can be successfully treated at the scene, conflicting results have been reported in other cases with complications days later [5].

In 1991, Thompson et al produced one of the earliest studies of treat-and-release protocols, and proposed five criteria that should be met before patients are released from prehospital treatment:

1. History of either T1DM or T2DM.
2. Pretreatment blood sugar of less than 4.4 mmol/L or 80mg/dL.
3. Post-treatment blood sugar equal or greater to 4.4 mmol/L or 80mg/dL.
4. Return to normal mental status within 10 minutes of treatment.
5. Absence of complicating factors that require ED evaluation, such as renal dialysis, chest pain, alcohol, dyspnea or falls.

Clinical manifestations of hypoglycemia are nonspecific, and can be divided into neurogenic and neuroglycopenic symptoms [6].

As reported by NEISS-CADES, patients over 80 years old have a higher risk of being hospitalized due to hypoglycemic events, since neuroglycopenic symptoms can mimic other cardiovascular and neurologic conditions.

Other studies regarding younger groups, involving T2DM and over the age of 50 and glycated hemoglobin (HbA1c), suggest that both extreme hyperglycemia and hypoglycemia contribute to poor outcomes when encountering a hypoglycemic event [7]. This can also be applicable for patients with T1DM with extreme values of HbA1c, as recurrent episodes of hypoglycemia and impaired awareness during these episodes are known major risk factors for these events.

Concerns about inappropriate use of sulfonylureas in the elderly and hospitalization rates due to hypoglycemic episodes have also been studied [8]. Around one-third of hypoglycemic episodes in the ED were exclusively related to sulfonylurea treatment, as they experienced prolonged hypoglycemia. Hospital admission of all patients under sulfonylurea treatment with hypoglycemia has been strongly recommended, with the argument that regardless of whether a resolution of hypoglycemia was reached in the ED, observation was needed. Moreover, treatment of hypoglycemia due to sulfonylurea includes octreotide administration [9].

The National Model EMS Clinical Guidelines (NASEMSO Model) published in 2017 facilitated hypoglycemia protocol [10]. Treatment is focused on the level of consciousness, patient disposition and initial neurological presentation. In a nutshell, a conscious patient with a patent airway can obtain oral glucose, with adults receiving approximately 25 grams of dextrose (at a concentration of 10 to 50 percent) and pediatric patients receiving 0.5-1g/kg (at a concentration of 10 to 25 percent).

Under NASEMSO Model, an unconscious patient will require dextrose IV with or without the use of Glucagon. A maximum of 25g of 10 to 50 percent dextrose IV was determined for adults and for children the 0.5-1g/kg of 10 to 25 percent dextrose IV. Patient is in need of transport if hypoglycemic symptoms continue or if patient had a seizure at any point during the episode. Release without transport should only be considered if patient meets all of the following:

1. Repeat glucose measurement over than 80mg/dL.
2. Patient takes insulin or metformin to control diabetes.
3. Patient returns to normal mental status, with no focal neurologic signs or symptoms after receiving glucose/dextrose.
4. Patient can promptly obtain and will eat a carbohydrate meal.
5. Patient or legal guardian refuses transport and EMS providers agree transport not indicated.
6. A reliable adult will be staying with patient.
7. No major co-morbid symptoms occur, such as chest pain, shortness of breath, seizures, intoxication.
8. A clear cause of the hypoglycemia is identified (e.g. skipped meal).

Regardless of national EMS guidelines established for hypoglycemia, there is still variability in EMS protocols throughout the U.S. [10-12]. Further studies are required to determine the reasons underlying these variations and patient outcome.

Case Scenario follow-up: Patient was given an early lunch at the office, had normal vital signs and normal EKG. Upon further questioning, patient indicates he did not eat breakfast because he was running late for work, but did administer his insulin. Patient denied any other symptoms and a coworker is able to stay and watch after the patient. Paramedics used their well-person protocol to determine if any abnormalities warranted further intervention. Assessed patient for capacity and oriented the patient about the need for close follow-up. Patient indicated he understood all orientations and refused further care.

Take home: Any patient with seizures, persistent symptoms of hypoglycemia and that does not comply with the NASEMSO Model for release without transport criteria should be taken to the emergency department for further evaluation.

About the author

David Arbona Calderon, MD, was born and raised in San Juan, Puerto Rico. He completed his emergency medicine residency in the city of Ponce, Puerto Rico at Hospital Episcopal San Lucas and is board certified in emergency medicine. He recently completed his EMS fellowship at the University of North Carolina at Chapel Hill (UNC).

References

1. Centers for Disease Control and Prevention. National diabetes statistics report: Estimates of diabetes and its burden in the United States, 2017. Atlanta, GA: US Department of Health and Human Services. 2017. https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf
2. Geller AI, Shehab N, Lovegrove MC, et al. National Estimates of Insulin-Related Hypoglycemia and Errors Leading to Emergency Department Visits and Hospitalizations. JAMA Intern Med. 2014;174(5):678–686. doi:10.1001/jamainternmed.2014.136
3. Lipska, K. J. et al. “Hba1c And Risk Of Severe Hypoglycemia In Type 2 Diabetes: The Diabetes And Aging Study.” Diabetes Care 36.11 (2013): 3535-3542. Web. 9 May 2018. https://doi.org/10.2337/dc13-0610
4. Roberts, K., and A. Smith. “Outcome of diabetic patients treated in the prehospital arena after a hypoglycemic episode, and an exploration of treat and release protocols: a review of the literature. (Prehospital Medicine).“ Emergency Medicine Journal, May 2003, p. 274+. Health Reference Center Academic. http://link.galegroup.com.ezproxyhost.library.tmc.edu/apps/doc/A102769958/HRCA?u=txshracd2509&sid=HRCA&xid=14527de1
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6. Hepburn, D. A. et al. “Symptoms Of Acute Insulin-Induced Hypoglycemia In Humans With And Without IDDM: Factor-Analysis Approach.” Diabetes Care 14.11 (1991): 949-957. Web. 9 May 2018.
7. Moheet, Amir, and Elizabeth R. Seaquist. “Hypoglycaemia, Emergency Care And Diabetes Mellitus.” Nature. N.p., 2014. Web. 9 May 2018.doi:10.1038/nrendo.2014.67
8. Rajendran R, Hodgkinson D, Rayman G. Patients with diabetes requiring emergency department care for hypoglycaemia: characteristics and long-term outcomes determined from multiple data sources. Postgraduate Medical Journal 2015;91:65-71. doi:10.1136/postgradmedj-2014-132926
9. McLaughlin, S. A., Crandall, C. S., & McKinney, P. E. (2000). Octreotide: an antidote for sulfonylurea-induced hypoglycemia. Annals of emergency medicine, 36(2), 133-138.
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