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Feb.16.2021

Hypoglycemia (Pediatric ED)

Clinical Description

  • Care of the Emergency Department pediatric patient seeking treatment for a low blood glucose level.

Key Information

  • Blood glucose value less than 70 mg/dL (3.9mmol/L) requires treatment.
  • Diabetic patients who experience frequent hypoglycemic events can develop hypoglycemic unawareness. This may result in dangerously low blood glucose levels that can lead to neurologic sequelae or death. Immediate medical attention is required.
  • Glucagon treatment can induce nausea and vomiting.
  • If a patient has recently ingested alcohol or has advanced hepatic disease, the treatment effect of glucagon is impaired.
  • In children, it is important to use the appropriate concentration of dextrose solution to avoid vein sclerosis and hyperosmolar state.
  • Oral antihyperglycemic agents, particularly sulfonylurea, can cause hypoglycemia. Due to the long-acting mechanism, repeated hypoglycemic events are likely, especially for those with renal impairment; lengthened observation time may be required.
  • Beta-Blocker medications mask the sympathetic epinephrine response to hypoglycemia; usual hypoglycemia symptoms may be absent.

Threats to Life, Limb or Function

  • blood glucose level below 54 mg/dL (milligrams per deciliter)
  • neurologic impairment

Clinical Goals

By transition of care

A. The patient will achieve the following goals:
  • Goal: Acute Signs/Symptoms are Managed

  • Goal: Acceptable Pain Level Achieved

    Correlate Health Status

    • Correlate health status to:

      • history, comorbidity, congenital anomaly
      • age, developmental level
      • sex, gender identity
      • baseline assessment data
      • physiologic status
      • response to medication and interventions
      • psychosocial status, social determinants of health
      • barriers to accessing care and services
      • child and family/caregiver:
        • health literacy
        • cultural and spiritual preferences
      • safety risks
      • family interaction
      • plan for transition of care

    Hypoglycemia

    Associated Documentation

    • Hypoglycemia Management

    Presentation

    • anxiety
    • emotional lability
    • inconsolable crying
    • irritability
    • lethargy
    • nervousness
    • palpitations
    • seizures
    • sweating
    • tremors
    • unresponsive

    Associated Signs/Symptoms

    • blurred vision
    • headache
    • hunger
    • mental status altered
    • nausea and vomiting
    • seizure activity
    • speech slurred

    Potential Causes

    • alcohol ingestion
    • drug-induced
    • excess insulin delivery
    • inability to identify symptoms
    • liver failure
    • mismatch of insulin dosing to carbohydrate consumption
    • missed meals or snacks
    • nausea and vomiting
    • oral intake decreased
    • physical activity without insulin or carbohydrate adjustment
    • pregnancy
    • renal failure
    • sepsis
    • toxic ingestion
    • toxicity
    • tumor

    Initial Assessment

    • neurologic status
    • point-of-care blood glucose level
    • signs and symptoms of intoxication or infection

    History

    • allergies
    • comorbidities
    • immunization status
    • last menstrual period (females of childbearing age)
    • medications
    • alcohol consumption
    • description of past hypoglycemia episodes
    • dietary intake
    • food security
    • frequency of hypoglycemia events
    • glucose monitoring technique (continuous glucose monitoring) and target range
    • hypoglycemia treatment attempted (carbohydrate, glucagon administration)
    • insulin administration (type, dose, delivery, schedule)
    • oral antihyperglycemic agents (type, dose, schedule)
    • recent activity
    • usual glycemic control

    Laboratory Studies

    • blood glucose level

    Diagnostic Results

    • ECG (electrocardiogram)

    Potential Additional Testing

    • albumin to creatinine ratio
    • BUN (blood urea nitrogen)
    • C peptide
    • cultures
    • glomerular filtration rate
    • liver function tests
    • pregnancy test (females of childbearing age)
    • serum creatinine
    • thyroid function tests
    • toxicology screen (serum and urine)

    Problem Intervention

    Monitor and Manage Hypoglycemia

    • Provide treatment; if alert and able to safely swallow; provide oral fast-acting carbohydrate, such as glucose tablet or gel, regular soda or juice. If not alert and unable to safely swallow, administer intravenous dextrose or intermuscular glucagon when intravenous access is not available.
    • Stop insulin pump therapy in unresponsive patient until the patient is alert and has regained function.
    • Retest blood glucose within 15 minutes; re-treat until blood glucose level is stabilized.
    • Recheck blood glucose level with change in mental or cognitive status.
    • Implement safety measures, such as aspiration precautions, seizure precautions and close supervision.
    • Assess need for and provide supportive measures, such as oxygen therapy, cardiac and oxygen saturation monitoring.
    • Identify potential cause to avoid reoccurrence and need for admission.
    • Provide additional snack or meal with carbohydrate, once alert; use caution not to over-treat.

    Education

    General Emergency Education

    Teaching Focus

    • symptom/problem overview

    • risk factors/triggers

    • self-management

    • assistive device

    • diagnostic test

    • diet modification

    • medical device/equipment use

    • medication administration

    • opioid medication management

    • orthopaedic device

    • safe medication disposal

    • smoking cessation

    • wound care

    Population-Specific Considerations

    Forensics and Legal

    • Utilize local, state/province, federal requirements and hospital policy and protocols to manage patient care involving forensics, protective services, workman’s compensation and mandatory reportable events and illness.

    Human Trafficking

    • Human trafficking victims most frequently seek healthcare services from Emergency Departments. Healthcare professionals, alert to signs of trafficking, can guide supportive care for victims.
    • Trafficked individuals may be male or female and engaged in sex work or other forced labor. High-risk signs requiring more direct questioning about exploitation include, among others, current employment in a high-risk industry, prior sexually transmitted infections, recent immigration and other vulnerable and minority populations, as well as children who are homeless, runaways or in foster care.

    Age-Related

    • Young children (less than 6 years of age) are particularly at risk for hypoglycemia, due to inability to recognize or identify hypoglycemic symptoms. Eating, snacking and sleeping habits are often unpredictable.
    • Puberty is associated with decreased attention to diabetes management, as well as increased insulin resistance.
    • Parents and caregivers need to be educated on recognizing the signs and symptoms of hypoglycemia.
    • Learning deficits and ongoing cognitive dysfunction may result from repeated episodes of severe hypoglycemia.

    Pregnancy

    • Beyond 20 weeks gestation, supine position should be avoided. Maternal position should be lateral or lateral tilt to prevent compression of the inferior vena cava and aorta by the pregnant uterus.
    • During first trimester, diabetic patients have increased insulin insensitivity and may be at increased risk of hypoglycemia events. This changes as the pregnancy progresses to second and third trimesters and insulin resistance escalates exponentially, increasing blood glucose levels and insulin requirements.

    Cultural Awareness

    • Fasting is a practice common to some cultures or religions, placing these patients at an increased risk for hypoglycemic events.

    References

    • Fernández Gómez, J., Ochoa Linares, M., Grajeda Ancca, P., Guzmán Calderón, E., Lugo Espinoza, M., Gonzáles Zarate, J. Prevención y control de las infecciones intrahospitalarias. Guía de precauciones de aislamiento hospitalario. Perú: Dirección regional de salud del Cusco y Dirección de epidemiología. Ministerio de Salud . 2006;Source[Clinical Practice Guidelines]
    • Abraham, M. B.; Jones, T. W.; Naranjo, D.; Karges, B.; Oduwole, A.; Tauschmann, M.; Maahs, D. M. ISPAD Clinical Practice Consensus Guidelines 2018: Assessment and management of hypoglycemia in children and adolescents with diabetes. Pediatric Diabetes. 2018;19, 178-192. [Quality Measures,Clinical Practice Guidelines]
    • Adams, J. G.; Barton, E. D.; Collings, J. L.; DeBlieux, P. M. C.; Gisondi, M. A.; Nadel, E. S. (2013). Emergency medicine clinical essentials. Philadelphia: Saunders, Elsevier. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • American Diabetes Association. American Diabetes Association Standards of Medical Care in Diabetes--2021. Diabetes Care. 2021, January;44(1), S1-S232. Source[Clinical Practice Guidelines]
    • American Diabetes Association. American Diabetes Association Standards of Medical Care in Diabetes--2021. Diabetes Care. 2021, January;44(1), S1-S232. Source[Clinical Practice Guidelines]
    • American Diabetes Association. Standards of medical care in diabetes. Diabetes Care. 2020;43(Supplement 1), S1-S211. doi:10.2337/dc20-SPPC Source[Quality Measures,Clinical Practice Guidelines]
    • American Diabetes Association. Summary of Revisions: Standards of Medical Care in Diabetes - 2021. Diabetes care. 2021;44(Suppl.1), S4 - S6. doi:10.2337/dc21-SREV [Clinical Practice Guidelines]
    • American Heart Association; The American Academy of Pediatrics. (2016). Pediatric advanced life support provider manual. United States: American Heart Association. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Association of Diabetes Care and Education Specialists. (2019). Managing low blood sugar. Source[Expert/Committee Opinion]
    • Battelino, T.; Danne, T.; Bergenstal, R.M.; Amiel, S.A.; Beck, R.; Biester, T.; Bosi, E.; Buckingham, B.A.; Cefalu, W.T.; Close, K.L.; Cobelli, C.. Clinical targets for continuous glucose monitoring data interpretation: recommendations from the international consensus on time in range. Diabetes care. 2019;42(8), 1593-1603. doi:10.2337/dci19-0028 [Expert/Committee Opinion]
    • Beltran, G.. Diabetic emergencies: New strategies for an old disease. Emergency Medicine Practice. 2014;16(6), 1-19. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Boido, A.; Ceriani, V.; Pontiroli, A. E.. Glucagon for hypoglycemic episodes in insulin-treated diabetic patients: A systematic review and meta-analysis with a comparison of glucagon with dextrose and of idfferent glucagon formulations. Acta Diabetologica. 2015;52(2), 405-412. doi:10.1007/s00592-014-0665-0 [Metasynthesis,Meta-analysis,Systematic Review]
    • Carlson, J. N.; Schunder-Tatzber, S.; Neilson, C. J.; Hood, N. Dietary sugars versus glucose tablets for first-aid treatment of symptomatic hypoglycaemia in awake patients with diabetes:  A systematic review and meta-analysis. Emergency Medicine Journal. 2017;34(2), 100-106. doi:10.1136/emermed-2015-205637 [Metasynthesis,Meta-analysis,Systematic Review]
    • Centers for Medicare & Medicaid Services (CMS). (2017). NQF 0495. Median Time from ED Arrival to ED Departure for Admitted ED Patients. Source[Quality Measures,Clinical Practice Guidelines]
    • Centers for Medicare & Medicaid Services (CMS). (2017). NQF 0496. Median time from ED arrival to ED departure for discharged ED patients. Source[Quality Measures,Clinical Practice Guidelines]
    • Emergency Nurses Association. (2018). Emergency nursing core curriculum. St. Louis: Elsevier. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Emergency Nurses Association. (2020). Sweet, V.; Foley, A (Eds.), Sheehy's Emergency Nursing Principles and Practice. St. Louis: Mosby, Elsevier. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Greenbaum, J.. Identifying victims of human trafficking in the emergency department. Clinical Pediatric Emergency Medicine. 2016;17(4), 241-248. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Hammond, B. B.; Zimmermann, P. G. (2013). Sheehy's manual of emergency care. St. Louis: Mosby, Elsevier. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Marx, J. A.; Hockberger, R. S.; Walls, R. M. (2018). Rosen's emergency medicine. Philadelphia: Elsevier. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Troiano, N. H.; Witcher, P. M.; McMurtry Baird, S.. (2019). AWHONN: High-risk & critical care obstetrics. Philadelphia: Wolters Kluwer. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • U. S. Department of Health and Human Services. (2017). Human trafficking webinar for health care providers: SOAR to health and wellness. Source[Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Villani, M.; de Courten, B.; Zoungas, S.. Emergency treatment of hypoglycaemia: A guideline and evidence review. Diabetic Medicine: A Journal of the British Diabetic Association. 2017;34(9), 1205-1211. doi:10.1111/dme.13379 [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Wolfsdorf, J. I.; Glaser, N.; Agus, M.; Fritsch, M.; Hanas, R.; Rewers, A.; Sperling, M. A.; Codner, E. ISPAD Clinical Practice Consensus Guidelines 2018: Diabetic ketoacidosis and the hyperglycemic hyperosmolar state. Pediatric Diabetes. 2018;19(Suppl 27), 155-177. doi:10.1111/pedi.12701 [Quality Measures,Clinical Practice Guidelines]
    • Yale, J. F.; Paty, B.; Senior, P. A. 2018 Clinical Practice Guidelines: Hypoglycemia. Canadian Journal of Diabetes. 2018;42(1), S104-S108. doi:10.1016/j.jcjd.2017.10.010 Source[Quality Measures,Clinical Practice Guidelines]

    Disclaimer

    Clinical Practice Guidelines represent a consistent/standardized approach to the care of patients with specific diagnoses. Care should always be individualized by adding patient specific information to the Plan of Care.

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