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HYPOGLYCEMIA

OVERVIEW
Normal fasting blood glucose levels range from 60-80 to 100 mg/dl.  Normal postprandial levels are less than 160 mg/dL at 2 hrs post ingestion. Chronic hypoglycemia is associated with long-term damage and dysfunction involving the eyes, kidneys, nerves, and heart.

Diabetes is a chronic endocrine disorder characterized by the onset of hypoglycemia.  There are two types of Diabetes, Type 1 and Type 2.  Type 2 diabetes accounts for 90% of the 20.8 million individuals affected by Diabetes.  Type 2 Diabetes typically occurs in adults 40yrs and older.  However, Type 2 Diabetes is reportedly on the rise in the younger population, particularly among the American Indian, African American, and Hispanic/Latino populations.  Type 1 Diabetes is a rarer form of diabetes, affecting only 10% of the diabetic population.  Type 1 Diabetes typically occurs in children and young adults.  Although Type 1 Diabetes is the rarer form of the disease it is the form of the disease most likely encountered by the sports medicine team as it typically affects individuals within the middle school, secondary school, college, and professional age groups.

Type 1 Diabetes  is an autoimmune disorder resulting in absolute insulin deficiency.  Type 1 diabetes is thought to be the result of genetic predisposition and unknown environmental factors.

Recognition and Management
The signs and symptoms of Type 1 diabetes develop rapidly and are related to hypoglycemia.  The typical signs and symptoms include:

⦁ Frequent urination;
⦁ Thirst;
⦁ Hunger;
⦁ Polyphasia;
⦁ Weight loss;
⦁ Visual disturbances;
⦁ Fatigue;
⦁ Ketosis.

Individuals diagnosed with diabetes are able to resume exercise within weeks of initiating proper insulin therapy, a comprehensive diabetic care treatment plan, and specific exercise guidelines overseen by a management team.  Considering specific recommendations from the American Diabetes Association and American College of Sports Medicine the management team will develop a comprehensive diabetic care plan designed to maintain consistent blood glucose concentrations at a near-normal range without provoking hyperglycemia.  The comprehensive diabetic care plan will provide for the following:

⦁ Blood glucose monitoring, including specific exclusion criteria;
⦁ Insulin therapy guidelines;
⦁ List of and access to all necessary medications and supplies;
⦁ Guidelines for hyper/hypoglycemia;
⦁ Emergency contact information;
⦁ Medic alert identification/tag.

A team approach is critical to the success of a diabetic treatment plan.  The medical support team will include physicians, including the athlete’s primary care and specialists, nurses, coaches, administration, and athletic trainers. Athletic trainers will be central to the comprehensive diabetic care plan, with daily responsibilities, including prevention, recognition, immediate care, exercise nutrition, hydration, exercise monitoring/modifications, and communication.

Glucagon Injection
With the onset of signs and symptoms of severe hypoglycemia, the medical team will activate EMS and prepare to administer appropriate glucagon injections in accordance with injector instructions.  Athletes may experience nausea and vomiting after glucagon injections.  Unconscious athletes should regain consciousness within 15 min following injection.  Athletes treated with glucagon injection may be provided food once conscious and able to swallow.  Athletes who are unable to consume food will be treated according to EMS protocol.
Patients may be in a coma from severe hyperglycemia rather than hypoglycemia.  In such cases, the patient will not respond to glucagon and requires immediate medical attention.
Glucagon kits should be stored at controlled room temperature between 20° to 25°C (68° to 77°F).   Glucagon solution should be used immediately.   Discard any unused portion.  Solutions should be clear and of a water-like consistency at time of use.

Use glucagon to treat insulin coma or insulin reaction resulting from severe hypoglycemia (low blood sugar). Symptoms of severe hypoglycemia include disorientation, unconsciousness, and seizures or convulsions. Give glucagon if (1) the patient is unconscious (2) the patient is unable to eat sugar or a sugar-sweetened product (3) the patient is having a seizure, or (4) repeated administration of sugar or a sugar-sweetened product such as a regular soft drink or fruit juice does not improve the patient’s condition. Milder cases of hypoglycemia should be treated promptly by eating sugar or a sugar-sweetened product. Glucagon is not active when taken orally.

To prepare glucagon for injection:

1. Remove the flip-off seal from the bottle of glucagon. Wipe rubber stopper on bottle with alcohol swab.

2. Remove the needle protector from the syringe, and inject the entire contents of the syringe into the bottle of glucagon. DO NOT REMOVE THE PLASTIC CLIP FROM THE SYRINGE. Remove syringe from the bottle.

3. Swirl bottle gently until glucagon dissolves completely. GLUCAGON SHOULD NOT BE USED UNLESS THE SOLUTION IS CLEAR AND OF A WATER-LIKE CONSISTENCY. TO INJECT GLUCAGON Use Same Technique as for Injecting Insulin

4.  Using the same syringe, hold bottle upside down and, making sure the needle tip remains in solution, gently withdraw all of the solution (1 mg mark on syringe) from bottle. The plastic clip on the syringe will prevent the rubber stopper from being pulled out of the syringe; however, if the plastic plunger rod separates from the rubber stopper, simply reinsert the rod by turning it clockwise. The usual adult dose is 1 mg (1 unit). For children weighing less than 44 lb (20 kg), give 1/2 adult dose (0.5 mg). For children, withdraw 1/2 of the solution from the bottle (0.5 mg mark on syringe). DISCARD UNUSED PORTION.

Glucagon Preparation Steps

 Step 1 Step 2 Step 3 Step 4

Use the following steps to inject glucagon immediately after mixing:

1. Cleanse injection site on buttock, arm, or thigh with alcohol swab;

2.  Insert the needle into the loose tissue under the cleansed injection site, and inject all (or 1/2 for children weighing less than 44 lb) of the glucagon solution. THERE IS NO DANGER OF OVERDOSE. Apply light pressure at the injection site, and withdraw the needle. Press an alcohol swab against the injection site;
3. Turn the patient on his/her side. When an unconscious person awakens, he/she may vomit. Turning the patient on his/her side will prevent him/her from choking;
4. FEED THE PATIENT AS SOON AS HE/SHE AWAKENS AND IS ABLE TO SWALLOW. Give the patient a fast-acting source of sugar (such as a regular soft drink or fruit juice) and a long-acting source of sugar (such as crackers and cheese or a meat sandwich). If the patient does not awaken within 15 minutes, give another dose of glucagon and INFORM A DOCTOR OR EMERGENCY SERVICES IMMEDIATELY;
5. Even if the glucagon revives the patient, his/her doctor should be promptly notified. A doctor should be notified whenever severe hypoglycemic reactions occur;
6. It is important to remember that patients may be in a coma from severe hyperglycemia rather than hypoglycemia.  In such cases, the patient will not respond to glucagon and requires immediate medical attention.

Severe side effects are very rare, although nausea and vomiting may occur occasionally. A few people may be allergic to glucagon or to one of the inactive ingredients in glucagon, or may experience rapid heartbeat for a short while. If you experience any other reactions which are likely to have been caused by glucagon, please contact your doctor.

Hyperglycemia occurs when renal glucose thresholds of 180 mg/dl are exceeded.  Hyperglycemia may result from poor glycemic control, acute care treatment of hypoglycemia or from exercise itself.  Some athletes may purposely train or compete in a hyperglycemia state to avoid hypoglycemia. Hyperglycemia results in ketoacidosis, hepatic glucose production, Catecholamine, FFA and keytone body production, and psychological stresses that are typically offset by counter-regulatory hormones in a normal state.  Hyperglycemia is associated with increased urination production, dehydration, and decreased athletic performance, relative to well-designed glycemic control measures.

Signs and symptoms of hyperglycemia include:

⦁ Rapid breathing;
⦁ Fruity breath;
⦁ Unusual fatigue;
⦁ Sleepiness;
⦁ Inattentiveness;
⦁ Loss of appetite;
⦁ Increased thirst;
⦁ Frequent urination.
To avoid complications associated with hyperglycemia, the medical team will follow current American Diabetic Association guidelines to avoid exercise during period of hyperglycemia, and may consider increasing basil rates or insulin boluses.

Insulin Injections and Insulin Pumps
For athletes using insulin injections to control their blood glucose levels, the medical team shall counsel athletes to avoid intramuscular injections; injecting instead in the subcutaneous tissues of the abdomen, upper thigh, or upper arm.  Heat and cold therapies may be contraindicated for 1-3hrs following injection of fast-acting insulin.  Insulin pump users will be counseled to replace insulin infusion sets every 2-3days.
Ambient temperatures <36 degrees F or >86 degrees F have been associated with reduced insulin action.  During these conditions the medical team may advise checking blood glucose concentrations more frequently.  The medical team may also counsel insulin pump users to replace cartridge and infusion sets with the onset of unusual hypoglycemia readings.

Travel Considerations
When airline travel is required the medical team will refer to Transportation Security Administration (TSA) guidelines concerning all diabetic instruments and medications.  Diabetic medical supplies and prescriptions will be carried with the athlete or a designated agent.  Diabetic medical supplies and prescriptions will not be stored in the cargo hold.  The medical team will advise all diabetic athletes to bring an appropriate prepacked meal or snack.  The medical team will also discuss and counsel appropriate adjustments to insulin therapy when traveling through time zones.

Prevention Guidelines
Prevention measures will be emphasized during the Preparticipation Physical Examination (PPE).  During the PPE the medical team shall counsel the athlete in the following:
1. Self-care skills;
2. Current status of glycemic control;
3. Discussion of how exercise affects blood glucose concentration;
4. Screening for complications;
5. Exclusion thresholds;
6. Bolus adjustments;
7. Acute care guidelines

In addition to the PPE the athlete shall have a regular annual exam with diabetic care specialists who will review:
1. GlycoHemo (HBAc) every 3-4mo
2. Overall glycemic control;
3. Retinopathy;
4. Nephrology
5. Neuropathy;
6. Cardiovascular screening.

Daily prevention of hypoglycemia will include a 3-prong approach that includes blood glucose monitoring, carbohydrate supplementation, and insulin adjustment.  Blood glucose monitoring will be monitored 2-3x at 30 minutes intervals prior to the onset of exercise, at 30 minute intervals during exercise, and every 2hrs for up to 4 hrs post-exercise.  Blood glucose levels will also be tested once before bed, once during the night, and upon awakening.
Athletes who present with pre-exercise blood glucose levels of < 100 mm/dl (5.5 mmmol/dl) will be provided approximately 30 grams of carbohydrates.  This will be accomplished through dietary supplementation, examples of which include, but are not limited to:

1. ½ peanut butter sandwich (1 slice of whole wheat bread + 1 Tbsp peanut butter) and 1 c milk;
2. 6 oz yogurt + ¼ c berries;
3. 1 English muffin + 1 teaspoon low-fat tub margarine

Carbohydrate supplementation may also be indicated for exercise bouts greater than 60min when pre-exercise insulin levels have not been reduced by 50%.  Diabetic athletes will be encouraged to eat a snack or meal shortly after cessation of exercise.

Insulin adjustments may also be indicated, particularly during moderate intensity exercise.  For athletes using insulin pumps the medical team may consider reducing basil rates by to 20-50% 1 to 2 hrs before exercise, reducing the bonus dose up to 50% at preceding meal, suspending or discontinuing pump at start exercise (< 60min). Insulin adjustments for athletes using multiple daily injections may include reducing bonus injections up to 50% at preceding meal.  The medical team may also consider adjusting the evening meal bolus by 50%.
Since prolonged or severe hypoglycemia may result in brain damage or death it is imperative for the medical team to be prepared to recognize and care for hypoglycemia. Signs and symptoms of hypoglycemia will generally present when blood glucose concentrations fall below 70 mg/dl.  These signed and symptoms will likely include:

⦁ Tachycardia;
⦁ Sweating;
⦁ Palpitations;
⦁ Hunger;
⦁ Nervousness;
⦁ Headache:
⦁ Trembling;
⦁ Dizziness.

Since prolonged or severe hypoglycemia may result in brain damage or death it imperative for the medica team to be prepared to recognize and care for hypoglycemia. Signs and symptoms of hypoglycemia will generally present when blood glucose concentrations fall below 70 mg/dl.  These signs and symptoms will likely include:

⦁ Tachycardia;
⦁ Sweating;
⦁ Palpitations;
⦁ Hunger;
⦁ Nervousness;
⦁ Headache:
⦁ Trembling;
⦁ Dizziness.

With the onset of signs and symptoms of mild hypoglycemia the medical team will be prepared to administer 10-15 g of fast acting carbohydrates. This may be accomplished via 4-8 glucose tablets or 2 Tbsp of honey.  Upon ingestion of fast-acting CHO supplement glucose concentrations will be measured.  Blood glucose concentrations will be measured again 15min following ingestion of fast-acting CHO supplement.  If blood glucose concentrations normalize, the athlete will be encouraged to consume a snack while 15min blood glucose serial measures are taken.  If blood glucose measures do not normalize after intention of fast-acting CHO supplement, the medical team may consider administering another 10-15 g of fast-acting CHO supplement.  If blood glucose levels do not normalize following a second round of fast-acting CHO supplementation, the medical team may elect to activate EMS.

As blood glucose concentrations continue to fall below 70 mg/dl athletes may begin to present with neurogenic symptoms indicative of sever hypoglycemia.  These signs and symptoms may include:

⦁ Signs and symptoms of mild hypoglycemia;
⦁ Blurred vision;
⦁ Fatigue;
⦁ Difficulty thinking;
⦁ Loss of motor control;
⦁ Aggressive behavior;
⦁ Seizures;
⦁ Convulsions;
⦁ Loss of consciousness.

Readiness Supplies
Basic Life Support Supplies
⦁ AED
⦁ BLS airway adjuncts
⦁ Hear rate monitor
⦁ Blood pressure monitor
⦁ Pulse oximeter

Protocol Specific Readiness Supplies:
⦁ Copy of the diabetic care plan;
⦁ Blood glucose monitoring equipment;
⦁ Supplies to treat hypoglycemia;
⦁ Supplies for urine or blood keytone testing;
⦁ Sharps container;
⦁ Spare batteries.