Administration and Leadership, Columns

Protocols Vary for Hypoglycemia Treatment Nationwide

Issue 6 and Volume 41.

The Research

Rostykus P, Kennel J, Adair K, et al. Variability in the treatment of prehospital hypoglycemia: A structured review of EMS protocols in the United States. Prehosp Emerg Care. March 1, 2016. [Epub ahead of print.]

The Science

This study was trying to determine how the concentration of dextrose, the threshold for hypoglycemia prompting treatment and transport considerations varied across nationwide hypoglycemia protocols.

The authors gained access to a survey of protocol sets used by the 50 largest population services, as well as 135 protocols from www.emsprotocols.org.

In the treatment of hypoglycemia in adults, they found 8% recommend using only D10, 22% call for either D10 or D50, and 70% call for only D50.

Eighty-five percent of protocols using D50 specified concentration dilution for pediatric patients. The vast majority (75%) specified 25 g of dextrose as the initial dose for adults and 0.5 g/kg for pediatrics. Both the median and mode glucose threshold for patients of all ages being treated for hypoglycemia was 60 mg/dL.

Ninety-seven percent of protocols permitted glucagon use if vascular access couldn’t be obtained, 32% recommended monitoring repeat blood sugar levels only, and 4% recommended using the Glasgow coma scale (GCS) only.

Monitoring both repeat blood sugar levels and GCS was listed in 31%, and 33% of protocols didn’t list a specification. Only 49% permitted non-transport of patients whose hypoglycemia had been corrected.

Their conclusion? “In the U.S., EMS protocols for the treatment of hypoglycemia vary significantly. Further studies are warranted to determine the factors underlying this variability and effects on patient outcomes.”

Medic Wesley Comments

I was a little confused—was this study about the variability in protocols across the country, or educating us about the possible benefits of using lower-dose glucose for hypoglycemic patients? I decided it was an opportunity to do both.

The variability is no surprise. Across the country, and even across town, protocols can vary. First and foremost, the blame should go to medical directors. The quality of protocols as measured in evidence-based medicine is a reflection of the amount of energy and dedication that a medical director gives to their service.

Some medical directors review studies like this one and work with provider consensus to develop the best protocols for their area. Other services are given direction by someone who’s less familiar with the prehospital environment. They simply cut and paste whatever is free online.

I’ve seen protocols for BLS first responders that mirror the skills of ALS providers because the medical director didn’t really know what their scope of practice was—or should be.

I have to agree that national protocols would solve the issue of variability. But this would impede an EMS service’s privilege of having an active, studious medical director able to advance protocols based on new evidence. We need to continue to educate medical directors and providers and advocate for changes where the evidence leads us.

The proper concentration of glucose should be reevaluated for patient care and not because of material shortages. Oh, don’t get me started on that!

Doc Wesley Comments

I hope Medic Wesley checked her blood sugar so we can rule it out as a cause for her confusion. As for me? I’m not the least bit confused.

Frankly, it’s disgraceful that EMS as a healthcare industry can’t decide on a standard approach to care for one of the most commonly encountered and simple conditions to fix.

Heck, we can’t even agree on the definition of hypoglycemia. Although 60 mg/dL was the most common, protocols in this study ranged from 40-120 mg/dL. My internist would have me on medication if my glucose was over 110 mg/dL!

We’re overdosing our patients on dextrose. The majority of hypoglycemia can be corrected with as little as 5 g of sugar for an adult. Giving 25 g causes significant hyperglycemia that results in days of increased management by the patient to return to normal levels.

Although this group did a wonderful job creating an initial blueprint, I wish they had examined the evidence more closely as it relates to dextrose concentration.

Adverse effects of 50% glucose include hyperglycemia, burning and injury to the vein, and the potential for limb loss in the event that D50 infiltrates out of the IV into the tissues.

As for Medic Wesley’s concern about medical directors, I’m more concerned that most of our agencies don’t have adequate direction. National EMS protocols would clearly benefit them.