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Diabetic management emphasizes tight glycemic control to prevent long‐term complications, such as heart disease, kidney disease, and blindness. Tight glycemic control is a fine line to walk, and occasional episodes of hypoglycemia may be expected. Severe hypoglycemia can be a surrogate measure for declining health. An epidemiologic analysis found that severe hypoglycemia is associated with a higher absolute risk of cardiovascular events and mortality [13]. Hypoglycemia, usually defined as a serum glucose concentration less than 70 mg/dL (3.8 mmol/L), is the most common endocrine emergency [9]. While hypoglycemia can occur in a variety of settings, it is most commonly a complication of the treatment of diabetes [14]. Estimates are that people with diabetes suffer mild (self‐treated) hypoglycemic events one to two times per week and that 30% of people with diabetes suffer severe hypoglycemic events annually [15–18].

Symptomatic hypoglycemia requires intervention to prevent organ compromise. Prehospital treatment options include oral glucose, IV dextrose, or IM glucagon. Oral glucose may be used in alert patients with intact swallowing mechanisms. For patients with decreased level of consciousness or concern for aspiration, administration of 50% dextrose IV has been the standard for many years. One study found an average blood glucose elevation of 166 mg/dL following administration of 50% dextrose (50 mL), but the response varied widely among patients (range: 37 mg/dL to 370 mg/dL) [19]. Dextrose administered IV results in a rapid onset of action (2‐5 minutes). There are, however, several reports in the literature of soft tissue injury secondary to extravasation, which can cause significant complications, including compartment syndrome and loss of limb [20, 21].

Dextrose as a 10% solution (D₁₀W) is becoming more commonly used due to its lower risk of skin or soft tissue injury should extravasation occur, diminished risk of hyperglycemia due to overcorrection of hypoglycemia, and lower cost relative to D₅₀W [22]. Recent observational cohort studies of patients receiving D₁₀W, and a randomized controlled trial comparing D₁₀W and D₅₀W, have demonstrated that D₁₀W administration is safe and effective for adults [14,23–25]. In the randomized trial, there was no difference in time to regain consciousness among hypoglycemic patients when comparing the administration of 10% dextrose versus 50% dextrose. In the cohort of 51 patients, 25 patients received a 10% dextrose solution and 26 received a 50% dextrose solution. Both groups had a median recovery time of 8 minutes. Patients in the 10% dextrose group received a median of 15 g less glucose than the 50% dextrose group to achieve the same response. Additionally, patients in the 10% dextrose group were less likely to have high glucose levels after treatment. Patients occasionally had difficulty bringing their glucose levels back into a normal range after treatment with 50% dextrose [24].

For patients in whom IV access cannot be achieved in a timely manner, the administration of IM glucagon provides a means of rescue. However, in alcoholic or malnourished patients with depleted glycogen storage, it is less likely to be beneficial. Recovery time may be significantly longer with glucagon than with dextrose, with response times of 8‐21 minutes depending on the severity of hypoglycemia. Although glucagon is generally considered as an IM drug, it has also been used successfully subcutaneously and intranasally [26–30]. Intranasal glucagon has been shown to have comparable efficacy to IM or subcutaneous glucagon and is devoid of most of the technical difficulties associated with administration of an injectable medication [31]. Both IM and intranasal glucagon elevate glucose levels, but the response is faster in those treated via the IM route [29]. Sibley et al. described the case of a diabetic hypoglycemic patient who was successfully treated with intranasal glucagon in the prehospital setting without further side effects or complications [30]. A prospective, open‐label study found that a single 3 mg dose of intranasal glucagon administered by caregivers was effective in treating moderate symptomatic hypoglycemic events in children and adolescents with type 1 diabetes [32]. A human factors study simulating treatment of severe hypoglycemia showed nasal delivery of glucagon to be much faster, with a higher success rate than injection, for trained caregivers of insulin‐using persons (16 seconds vs. 1.9 minutes for time to administer, 94% vs. 50% for successful delivery) and for untrained acquaintances (26 seconds vs. 2.4 minutes, 93% vs. 20% for successful delivery) for intranasal and IM administrations, respectively [33, 34]. At present, intranasal glucagon costs more than IM glucagon, but the ability to treat patients quicker and with less training may reduce the need for advanced life support response and hospital visits, lessening the overall burden in the health system.

Intraosseous access is another potential route to provide dextrose for critically ill hypoglycemic patients without IV access. However, this should be reserved for severe clinical circumstances given that intraosseous insertion poses a risk for infection or poor wound healing in diabetic patients.