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The disposition of diabetic prehospital patients with successfully corrected hypoglycemia has been controversial. The concern for adverse outcomes, recurrent hypoglycemia, poor access to care, and possible litigation has fueled the discussion. A retrospective analysis, relying on 2013 data from the National EMS Information System and additional national surveys, found that approximately 20% of prehospital patients treated for hypoglycemia are not transported from the scene [45]. The practice of releasing treated hypoglycemic patients appears to be safe, particularly in the context of structured “treat and release” protocols [1,46–48].

A study of the reasons for EMS nontransport after a 9‐1‐1 call demonstrated that diabetic calls represent approximately 9% of nontransports. Previous studies had reported diabetes accounting for 2%‐7% of nontransports [49]. Studies examining the outcomes of patients who refuse transport reveal that they are no more likely than transported patients to experience recurrence of hypoglycemia or to require later care. Through these studies, a set of reasonable guidelines have been derived for refusal of care instructions. A patient should be able to eat, have a responsible adult who will remain with him or her, and not have any condition that would predispose the patient to a repeat episode, such as persistent vomiting. Additionally, the patient should receive written instructions directing physician follow‐up [1, 50, 51]. Research has shown that patients prefer a protocol that allows discharge of hypoglycemic patients without transport to the ED [52]. The burden of hypoglycemia to the health care system could potentially be reduced with implementation and appropriate use of EMS treat‐and‐release protocols, along with programs to educate patients on hypoglycemia risk factors and emergency preparedness [45]. EMS systems should develop specific guidelines for patient refusal after hypoglycemia treatment. The most important elements for these prehospital guidelines are summarized in Table 20.3.

Table 20.2 Pediatric dextrose administration

Source: Courtesy of The Office of the Medical Director, Austin/Travis County EMS System.

Dose 1.0 g/kgConcentration is 1 g/10 mL in 250 mL bag sterile water (D10W)Must use volume control device (IV burette) for infusionTitrate to patient’s condition and response
Patient weight	3 kg	5 kg	7 kg	9 kg	11 kg	13 kg	15 kg	17 kg
Desired dose	1 G	1 G	1 G	1 G	1 G	1 G	1 G	1 G
Grams Dextrose	3 g	5 g	7 g	9 g	11 g	13 g	15 g	17 g
mL D10w	30 mL	50 mL	70 mL	90 mL	110 mL	130 mL	150 mL	170 mL
Patient weight	19 kg	21 kg	23 kg	25 kg	27 kg	30 kg	33 kg	35 kg
Desired dose	1 G	1 G	1 G	1 G	1 G	1 G	1 G	1 G
Grams Dextrose	19 g	21 g	23 g	25 g	25 g	25 g	25 g	25 g
mL D10w	190 mL	210 mL	230 mL	250 mL	250 mL	250 mL	250 mL	250 mL

Table 20.3 Key elements for safe discharge after treatment for hypoglycemia

History of insulin‐dependent diabetes mellitus.Return of normal mental state within 10 minutes of dextrose administration.Pretreatment blood glucose less than 80 mg/dL.Posttreatment blood glucose greater than 80 mg/dL.Ability to tolerate food by mouth.Absence of comorbid conditions or complicating factors.The patient has follow‐up with a primary care physician.No use of sulfonylurea medications.Normal vital signs after treatment.Patient understands discharge instructions.Patient has a responsible adult to monitor him/her.