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Three Part Question

Are [recovered diabetic patients] who have been treated with [IM glucagon for hypoglycaemia by paramedic staff] [safe to be left at home]?

Clinical Scenario

Following a 999 call to their home, an adult insulin-dependent diabetic patient is successfully treated with IM glucagon for hypoglycaemia by the attending ambulance crew. The patient is now fully recovered, they feel fine and their blood glucose level is above 5mmol/l. The patient does not want to go to hospital so is it safe to leave them at home?

Search Strategy

Medline 1966-07/03 using the PubMed interface.
(diabet*OR diabetic* OR hypoglc*) AND (glucag*OR treatment*OR treatment refusal) AND (paramedic OR ambulance OR emergenc* OR prehosp* OR pre-hosp*) LIMIT to human AND English

Search Outcome

202 papers found but, as Roberts and Smith carried out a comprehensive literature review in July 2001 (1,4), only included relevant papers published after this date. See reference section for additional papers deemed to be relevant but already included in the Smith and Roberts review.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Roberts K & Smith A, 2003, UK	Patients treated for hypoglycaemia in pre-hospital environment	Literature review	Safety of treat & release practice	Based on evidence found safe for 90% patients. Produced set of recommend-ations for patients who should be transported which includes patients treated with IM glucagon as risk of relapse.	Outdated literature, need for RCT
Lerner EB, 2003, USA	36 insulin dependent diabetics treated for hypoglycaemia with IV glucose and left at home	Prospective, observational study	Complications 24 hours after treatment	91% no complications, 2 patients had recurrent hypos but treated themselves. 100% of patients in survey favoured protocol allowing them to be left at home	Inclusion & excusion criteria not followed consistently Not all patients received same treatment eg 50% glucose, 10% glucose, food and only I patient received glucagon
Carter AJ et al, 2002, Canada	100 patients treated with IV dextrose for hypoglycaemia	Telephone survey	Seeking medical treatment in the 3 days following treatment	68% refused transport - average age 47.Transported patients average age 64.7. No difference in repeat access to health care and in both groups satisfaction was high	Does not specify what repeat medical treatment was sought
Anderson S et al, 2002, Denmark	1148 hypoglycaemic patients – 87% treated with IV glucose, 2% with IM glucagon	Retrospective study	72 hour follow-up	968 (84%) patients left at home – 862 of which no secondary contact.	MICU in Denmark staffed by doctors – not directly comparable with UK

Comment(s)

There appears to be an increasing body of evidence to suggest that in the majority of cases it is safe to leave recovered hypoglycaemic patients at home. However there is very little specific evidence relating to treatment with IM glucagon as the vast majority of patients in these studies have been treated with IV glucose.

Clinical Bottom Line

There is little evidence to show that it is safe to leave patients who have been treated with IM glucagon for hypoglycaemia at home. This is an area that urgently requires more research so that standardised treat and release protocols can be established and implemented in the pre-hospital environment.

References

1. Roberts K, Smith A. Outcome of diabetic patients treated in the prehospital arena after a hypoglycaemic episode, and an exploration of treat and release protocols: a review of the literature. Emerg Med J 2003;20:274-276.
2. Roberts K and Smith A. The Pre-hospital management of hypoglycaemia: a review of the literature. Report for The Wales Office of Research and Development for Health and Social Care . Report for The Wales Office of Research and Development for Health and Social Care, July 2001.
3. Lerner E B, Billittier A J 4th, Lance D R et al. Can paramedics safely treat and discharge hypoglycaemic patients in the field? Am J Emerg Med 2003 Mar;21(2):115-20.
4. Carter AJ, Keane PS, Dreyer JF. Transport refusal by hypoglycaemic patients after on-scene intravenous dextrose. Acad Emerg Med 2002;9(8):855-7.
5. Anderson S, Hogskilde P D, Wetterslev J et al. Appropriateness of leaving emergency medical service treated hypoglycemic patients at home: a retrospective study. Acta Anaesthesiol Scand 2002;46(4):464-8.
6. Murphy P, Colwell C. Prehospital management of diabetes. Emerg Med Serv 2000;29(10):78-85.