Treating Hypoglycemia in the Field
Hypoglycemia is one of the most common and most treatable causes of altered mental status encountered in EMS. Dextrose administration rapidly restores blood glucose levels and can produce a dramatic reversal of symptoms. However, the concentration, route, and rate of dextrose administration matter significantly, especially in different patient populations.
Dextrose Concentrations
D50 (50% Dextrose)
D50W is the traditional formulation used in adult prehospital care. Each 50 mL prefilled syringe contains 25 grams of dextrose. It is administered IV push at a rate of approximately 25 mL per minute. D50 is highly hypertonic and caustic to veins, and extravasation can cause significant tissue necrosis. It must be administered through a well-functioning IV in a large vein.
D10 (10% Dextrose)
D10W is increasingly replacing D50 in many EMS systems. It is less hypertonic, gentler on veins, allows for more precise dose titration, and is less likely to cause rebound hyperglycemia. The standard dose is 100 to 250 mL (10 to 25 grams of dextrose) IV. D10 is preferred for patients with peripheral IVs, diabetics where overshooting glucose levels is a concern, and for use through IO access.
D25 (25% Dextrose)
D25W is the preferred concentration for pediatric patients. The dose is 0.5 to 1 g/kg IV. For infants under 6 months, D10W at 5 mL/kg is used because even D25 is too concentrated for neonatal veins.
Clinical Pearls
- Always confirm hypoglycemia with a glucometer before administering dextrose (typical threshold is below 60 mg/dL with symptoms)
- Recheck blood glucose 5 to 10 minutes after administration
- Consider the cause of hypoglycemia: sulfonylurea-induced hypoglycemia may recur and require repeat dosing
- If IV access cannot be established, glucagon 1 mg IM is the alternative for unconscious patients
- For conscious patients who can protect their airway, oral glucose or juice is appropriate
- Thiamine (100 mg IV) should be administered before or with dextrose in patients with suspected chronic alcohol use to prevent Wernicke encephalopathy
IO Administration
When IO access is the only vascular route available, use D10W instead of D50 to reduce the risk of osteomyelitis and marrow damage from the hyperosmolar solution. Flush the IO line with normal saline after dextrose administration.