Hypoglycemia in the Outpatient Setting

Hypoglycemia is one of the most frequent—and potentially fatal—complications in people with diabetes. It’s something every urgent care and primary care clinician must be ready to manage quickly and effectively. But in the outpatient world, where IV setups may be sparse and you don’t have an entire emergency department team to rely on, what’s the safest and fastest way to handle a crashing blood sugar?

How is Hypoglycemia Defined?

The American Diabetes Association (ADA) defines hypoglycemia as a blood glucose level below 70 mg/dL.

In diabetics, this can occur secondary to: 

• Skipping a meal or not eating enough

• Taking too much insulin or oral antihyperglycemics

• Increased physical activity without adjusting insulin or food intake

In non-diabetics, possible triggers include:

• Depleted glycogen stores (e.g., prolonged fasting, alcohol abuse)

• Stress states, like infection, especially in infants and small children

Hypoglycemia Symptoms

1. Neuroglycopenic symptoms (due to lack of glucose in the brain):

• Confusion, agitation, lethargy, clumsiness, poor coordination, seizures or focal neurological deficits

2. Hyperepinephrinemia symptoms (due to epinephrine surge):

• Diaphoresis, pallor, shakiness, tachycardia, dizziness, weakness, nausea

These are alarming hypoglycemia symptoms that can mimic a stroke, seizure, psychosis, or drug overdose—so the quicker we can obtain a finger stick, the better.

Treatment in the Awake, Alert Patient: The 15-15 Rule

• Step 1: Give 15g of fast-absorbing carbohydrates.

• Step 2: Recheck blood glucose in 15 minutes.

Repeat if blood sugar remains <70 mg/dL.  Once normalized, a follow-up meal or snack containing both carbohydrates and protein is crucial to prevent another crash. 

Examples of fast-acting carbs perfect for hypoglycemic management:

• 1 tablespoon of sugar or honey

• 4 oz of fruit juice or regular soda

• 1 small box of raisins

• 5–8 jellybeans or one fun-size bag of Skittles

• 3–4 glucose tablets (over-the-counter)

Pro tip: Print or laminate a cheat sheet with these options and keep it handy in exam rooms.

Treatment of the Altered Patient Who Cannot Tolerate PO

IV Access → Use Dextrose

No IV Access → Use Glucagon

Glucagon (released by the pancreas) triggers glycogen release from the liver to raise blood sugar, but it only works if glycogen stores are intact. Always follow up with food once the patient is stable to replenish these glycogen stores. Expect a 50–100 point rise in blood glucose within 30 minutes. A second dose may be given after 15 minutes if there’s no response. There is risk of nausea or vomiting, so be sure to maintain a patent airway. See the chart below for available forms:

Disposition

Consider outpatient management if:

• They had a brief episode and fully recovered

• They can eat and tolerate PO intake

• They’re not on long-acting agents

• They have no major comorbidities

• A responsible adult can stay with them

While many hypoglycemic episodes can be safely managed and discharged from urgent care, the below red flags warrant transfer:

• Hypoglycemia due to long-acting insulin or oral agents (i.e., sulfonylureas with 24-hour half-lives)

• Recurrent episodes or failure to maintain normal glucose levels

• Persistent neurological deficits

Patient Education

Make sure your patients understand:

• It’s okay—and necessary—for their blood sugar to run a little high temporarily post-episode.

• They should eat a balanced meal with carbs and protein soon after recovery.

• If they experience repeated severe lows, they need a higher level of care.

• Follow-up with a primary care provider or endocrinologist is a must.

Takeaways

Hypoglycemia can be sneaky and dangerous, but with a quick response and minimal resources, outpatient clinicians can effectively stabilize patients and prevent complications. Whether you’re using jellybeans or glucagon, your rapid intervention can save lives, and thorough education can help your patients stay safe and well-informed once they leave your care.

🎧 Want to learn more? Hear the full discussion between Urgent Care Reviews and Perspectives host Dr. Tiffany Proffitt and Primary Care Reviews and Perspectives host Dr. Neda Frayha in our podcast episode, “Sugar S.O.S.: Navigating Hypoglycemia in the Urgent Care.”