Bedside Snapshot

Use It For: Symptomatic hypoglycemia when the patient cannot safely swallow; with insulin for hyperkalemia; adult DKA/HHS fluids once glucose <250 mg/dL; neonatal hypoglycemia (D10 only)
Adult Dose: Hypoglycemia: 10 g IV (100 mL D10), or 5 g steps, until alert (field max 25 g)
Alternative: 10–25 g D50 slow IV into a large vein
Hyperkalemia: 25 g IV with regular insulin 10 units (D50 50 g in arrest)
Pediatric Dose: 0.5–1 g/kg IV/IO (max 25 g): D10 5–10 mL/kg preferred. Neonates: D10 2 mL/kg, then infusion. No D50 under 8 yr
Onset / Duration: IV: glucose rises within minutes; median 8 min to full GCS 15 / variable: an insulin or sulfonylurea outlasts the bolus
Do Not Give / Hold If: Patient alert and able to swallow (give oral glucose); rescue bolus with hyperglycemia; D25/D50 into a small or doubtful peripheral vein; dextrose hypersensitivity
Watch For: Extravasation (site pain, swelling); overshoot hyperglycemia (recheck at 15 min); rebound hypoglycemia (repeat checks for hours); low K⁺ with insulin
Reversal / Rescue: No antidote: stop the infusion. Extravasation: stop and follow the extravasation protocol. Recurrent lows: infusion plus food; octreotide for sulfonylureas
Must Remember: Order and document grams, not mL: 25 g = 50 mL D50 = 250 mL D10. D10 in 5–10 g steps works as fast as D50 with less overshoot

Indications

Emergency & Prehospital

Symptomatic hypoglycemia in a patient who cannot safely swallow: the patient has altered mental status, is seizing or is unresponsive. If they are alert, oral glucose comes first.
Low glucose found with altered mental status, seizure or stroke-like deficits: every one of these patients gets a glucose check. Correct the low before you blame the deficit on something else.
Insulin-induced hypoglycemia: missed meal, insulin pump problem or insulin overdose (the labeled indication for D50)
Sulfonylurea hypoglycemia: initial correction, followed by octreotide rather than repeated boluses

ED / ICU / Transport

Hyperkalemia treated with insulin: dextrose is there to stop insulin-induced hypoglycemia before it starts (see insulin)
Diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS): add 5–10% dextrose to the IV fluids once glucose falls, so insulin can keep running. Adult and pediatric thresholds differ (see D5W)
Persistent or recurrent hypoglycemia: D10 or more concentrated infusions after long-acting insulin or sulfonylurea overdose
High-dose insulin therapy for β-blocker or calcium channel blocker poisoning: a dextrose infusion keeps glucose normal while the insulin runs (off-label)
Neonatal hypoglycemia: D10 bolus and infusion. Stronger solutions only under NICU protocol.

Composition

Component	D10	D25	D50	Meaning
Dextrose per liter	100 g (100 mg/mL)	250 g (250 mg/mL)	500 g (500 mg/mL)	Normal fasting plasma glucose is 70–100 mg/dL
Common US container	250 mL bag = 25 g	10 mL syringe = 2.5 g	50 mL syringe or vial = 25 g	Same 25 g whether 250 mL D10 or 50 mL D50
Energy	340 kcal/L	850 kcal/L	1,700 kcal/L	3.4 kcal per gram of hydrous dextrose
Osmolarity (calc.)	505 mOsm/L	1,390 mOsm/L (label)	2,530 mOsm/L	All hypertonic; above 900 mOsm/L (D25, D50) labels call for a central or large peripheral vein (central only for D50 at 2–11 yr and the D25 infant syringe)
pH	3.2–6.5	3.2–6.5	3.2–6.5	Acidic; contributes to vein irritation
Na⁺, K⁺, Cl⁻, buffer	None	None	None	Electrolyte-free: becomes free water once the glucose is used

Free water: once the glucose enters cells, the leftover water spreads across total body water. Prolonged infusions can lower Na⁺
Volume: rescue boluses are small. Prolonged D10 infusions add real volume, and that matters in heart failure, kidney failure and small infants
Source: US dextrose is corn-derived. Regional products and labeled osmolarity values differ slightly.

Dosing & Administration

Hypoglycemia doses follow NASEMSO v3.0 (see Pediatric Dosing below). For hyperkalemia, DKA/HHS and high-dose insulin therapy, doses vary by protocol. Follow local protocols and medical direction. For neonates, use D10. Stronger solutions only under NICU protocol.

Available Forms

D10 (100 mg/mL): 250, 500 and 1,000 mL bags. 250 mL = 25 g. The form many EMS systems now carry for hypoglycemia.
D25 (250 mg/mL): 2.5 g/10 mL single-dose infant syringe. FDA-labeled from birth to under 2 yr at 1–2 mL/kg (250–500 mg/kg), by slow IV into a central vein only. Some EMS systems use D25 for adults (100 mL = 25 g).
D50 (500 mg/mL): 25 g/50 mL single-dose syringe and vial. Labeled for age 2 yr and older.
Other: buccal 40% dextrose gel (neonatal units). Oral glucose tablets and gel for alert patients. D5W is too dilute for rescue.

High-Alert Medication: Dextrose 20% or stronger (D25, D50) is on the ISMP high-alert list. The common errors: mL for gram (50 mL of D10 is 5 g, not 25 g), grabbing the wrong concentration and peripheral extravasation. Order and verify in grams plus concentration. Double-check every infusion and every pediatric dose, independently.

Adult Dosing

Indication	Dose & Route	Repeat / Max	Notes
Hypoglycemia, cannot swallow (D10 preferred)	10 g IV (100 mL D10), or 5 g (50 mL) steps; IO if no IV access	Recheck mental status and glucose after each step; repeat until alert. Field max 25 g (250 mL D10), then continue per medical direction	D10 is not high-alert. In a prehospital trial, 5 g D10 steps woke patients as fast as D50 (median 8 min), with a median 10 g given and lower post-treatment glucose.
Hypoglycemia, D50 or D25 alternative	10–25 g slow IV (20–50 mL D50, or 40–100 mL D25) into a large or central vein	Repeat as clinically appropriate; field max 25 g per dosing episode	High-alert Osmolarity above 900 mOsm/L: confirm a free-flowing line before and during the push; stop at the first sign of pain or swelling.
Persistent or recurrent hypoglycemia (long-acting insulin, insulin overdose)	D10 infusion after the bolus (example: 100 mL/hr = 10 g/hr)	No fixed max: titrate to glucose 100–200 mg/dL; labeled max rate without hyperglycemia 0.5 g/kg/hr	D20 or stronger needs a central line. Feed as soon as the patient can eat.
Sulfonylurea hypoglycemia	Correct with a bolus as above, then octreotide 50–100 mcg subcut (preferred) or IV	Octreotide every 6–12 hr as needed; observe at least 12 hr after dextrose and octreotide stop	No prophylactic dextrose before hypoglycemia occurs. Repeated boluses stimulate insulin release and cause rebound.
Hyperkalemia (with insulin)	25 g IV (50 mL D50 or 250 mL D10) with regular insulin 10 units IV	If pre-treatment glucose <126 mg/dL (7.0 mmol/L): add D10 50 mL/hr for 5 hr (25 g)	High-alert (D50). UK regimen: insulin mixed in 50 mL D50, given IV over 5–15 min into a large vein. Hypoglycemia can appear hours later: check glucose every 30 min for 2 hr, then hourly to at least 6 hr (longer if high risk, such as repeat doses). US protocols vary: insulin 5 or 10 units, and dextrose reduced or omitted when pre-treatment glucose is already high (cutoffs vary by protocol). In DKA/HHS follow the DKA/HHS protocol. Arrest (AHA 2025 Table 3; insulin with glucose in arrest is COR 2b, effectiveness not well established): D50 50 g IV bolus with insulin 10 units, a larger glucose dose than the 25 g regimen above. See insulin for insulin dosing.
High-dose insulin therapy, β-blocker or CCB poisoning (off-label)	If glucose is below 200 mg/dL (11 mmol/L), consider D50W 50 mL (25 g) IV before insulin; then D10 in 0.45% saline at 100 mL/hr	Boluses or D25/D50 as needed to keep glucose 100–200 mg/dL; no fixed max	High-alert (D50). Differs from FDA label: the D50 labeling covers hypoglycemia only. Per the Ontario Poison Centre 2024 protocol, beta-blocker poisoning often needs more glucose, CCB glucose needs can rise as toxicity improves, and supplemental dextrose may be needed for up to 24 hr after the insulin infusion stops. Insulin dosing: see insulin.
DKA, adult (and mixed DKA/HHS)	Add dextrose 5–10% to the IV fluids once glucose is <250 mg/dL	No fixed max: adjust with insulin to keep glucose about 150–200 mg/dL until ketoacidosis resolves	Insulin infusion drops to 0.05 units/kg/hr at this point. Euglycemic DKA (SGLT2 inhibitor): add dextrose early, alongside insulin.
Pure HHS, adult (little or no ketosis)	Add dextrose 5–10% to the IV fluids once glucose is <250 mg/dL	No fixed max: keep glucose 200–250 mg/dL until resolution; lower it by no more than 90–120 mg/dL/hr	Insulin starts at 0.05 units/kg/hr. HHS resolves when osmolality is <300 mOsm/kg, urine output >0.5 mL/kg/hr and glucose <250 mg/dL, with mental status improved.

Pediatric Dosing

Indication	Dose (per kg) & Route	Max Single / Max Total	Notes
Hypoglycemia, infant or child (not neonate)	0.5–1 g/kg IV/IO: D10 5–10 mL/kg (preferred), or D25 2–4 mL/kg in children over 8 yr	Max 25 g/dose; reassess after each dose and repeat if still low	D10 is preferred at every age; NASEMSO states it can be used safely in all ages. Dose on actual weight (weight-based dosing).
Age 12 yr and older	Adult dosing: 10–25 g IV	Max 25 g/dose	D50 label applies adult dosing from age 12 yr; D10 remains preferred.
D50 in younger children	Avoid under age 8 yr (NASEMSO); D50 label: not for age <2 yr, central vein only at 2–11 yr	—	Use D10 instead.
Neonatal hypoglycemia (symptomatic or very low)	D10 2 mL/kg (200 mg/kg) IV, then D10 infusion 80 mL/kg/day (GIR 5.5 mg/kg/min)	Recheck within 30 min; total fluids ≤100 mL/kg/day; GIR >10 mg/kg/min needed: specialist evaluation	Field or peripheral: no more than 10–12.5% under 1 month (NASEMSO). The D25 infant syringe (1–2 mL/kg) goes only by slow IV into a central vein, per NICU protocol; never D50. Symptomatic newborn: buccal 40% dextrose gel 0.5 mL/kg (200 mg/kg) can temporize while IV access is obtained, but does not replace IV D10. Asymptomatic at-risk newborn: gel with a feed, per NICU protocol.
Sulfonylurea exposure (child)	Octreotide 1–2 mcg/kg subcut or IV after dextrose correction	Every 6–12 hr as needed; not above the adult dose	Small doses can cause hypoglycemia in children. Observe asymptomatic children 12 hr (until morning if that ends at night); no prophylactic IV dextrose.
DKA (child)	Add dextrose (usually 5%) to the IV fluids when glucose falls to about 250–300 mg/dL (14–17 mmol/L), or earlier if it is falling faster than about 90 mg/dL/hr (5 mmol/L/hr) after the initial fluids	No fixed max: D10–D12.5 may be needed to keep insulin running until acidosis resolves	ISPAD 2022 pediatric thresholds differ from the adult ones. Cerebral edema risk.
Hyperkalemia (child)	D10 5 mL/kg (0.5 g/kg) IV with insulin 0.1 units/kg (max 10 units) over 15–30 min (AHA 2025 Table 3, stated for arrest; non-arrest use per pediatric protocol)	Insulin max 10 units; dextrose max not stated	Stated for arrest in AHA Table 3. Give the dextrose with insulin and check glucose per protocol.
High-dose insulin therapy, child (β-blocker or CCB poisoning, off-label)	If glucose is below 200 mg/dL (11 mmol/L): D25W 2–4 mL/kg (0.5–1 g/kg) IV before insulin; then D10 maintenance at an age-appropriate rate	No fixed max: titrate to glucose 100–200 mg/dL	Differs from FDA label: the D25 label covers hypoglycemia from birth to under 2 yr at 1-2 mL/kg by slow IV into a central vein. Insulin dosing: see insulin.

Continuous Infusion

Setting	Example Concentration	Start	Titrate	Usual Range / Max
Recurrent hypoglycemia (adult)	D10 (example, institution-specific)	Example: 100 mL/hr (10 g/hr)	To glucose 100–200 mg/dL	Label: 0.5 g/kg/hr max without hyperglycemia; D20 or stronger central
After insulin for hyperkalemia	D10	50 mL/hr if pre-treatment glucose <126 mg/dL	Fixed: 5 hr (25 g)	Target glucose 72–126 mg/dL (4–7 mmol/L)
Neonatal hypoglycemia	D10	80 mL/kg/day (GIR 5.5 mg/kg/min)	Rate or concentration to target glucose	GIR >10 mg/kg/min: investigate, specialist referral. Field: D10 (no more than 10–12.5% under 1 month). NICU: concentration per unit protocol (CPS supports peripheral up to 20%)
DKA or HHS (adult)	D5–D10 with 0.9% saline	When glucose <250 mg/dL	With the insulin infusion (0.05 units/kg/hr)	DKA: glucose about 150–200 mg/dL until ketoacidosis resolves. HHS: glucose 200–250 mg/dL, falling no faster than 90–120 mg/dL/hr, until osmolality <300 mOsm/kg, urine output >0.5 mL/kg/hr and glucose <250 mg/dL. Children: see Pediatric Dosing

Glucose infusion rate (GIR)

GIR (mg/kg/min) = dextrose % × rate (mL/hr) ÷ (6 × weight in kg)

Preparation & Administration

Think in grams: grams = % × mL ÷ 100. 25 g = 50 mL D50 = 100 mL D25 = 250 mL D10.
D10 technique: give measured 50–100 mL aliquots through a patent IV or IO line by syringe or volume-controlled set. Reassess between aliquots.
D25 and D50: push slowly into a large peripheral or central vein through a free-flowing line. Check blood return first. Central only for D25 in infants and for D50 at 2–11 yr.
Line: stop at the first pain, swelling or blanching. Never subcut or IM.
Glucose first: check glucose before dosing when possible, but never delay treatment in an emergency.
Blood: never through the same set as blood products (pseudoagglutination).
Pump: run every infusion on a pump. Single-dose containers: discard the unused portion.

Dosing Notes:

Rule of 50: dextrose % × mL/kg = 50 gives 0.5 g/kg. That is D10 at 5 mL/kg or D25 at 2 mL/kg.
Thresholds: treat hypoglycemia at glucose below 70 mg/dL (ADA Level 1). Level 2 is below 54 mg/dL. Level 3 is altered mental or physical status needing assistance at any glucose. The NASEMSO model guideline differs: it treats symptomatic patients at 60 mg/dL or less.
Once awake, feed a carbohydrate meal. The bolus wears off before insulin or a sulfonylurea does.
Renal and hepatic considerations: see Special Populations.

Contraindications & Precautions

Contraindications

Known hypersensitivity to dextrose (corn-derived)
The D25 and D50 labels also list intracranial or intraspinal hemorrhage, severe dehydration and (D50) alcohol withdrawal. Confirmed hypoglycemia still gets corrected in these patients. Use D10 to a normal glucose, avoid overshoot and involve medical direction.

Precautions

Hypoglycemia rescue boluses: do not give a rescue bolus with hyperglycemia or without documented or strongly suspected hypoglycemia. The exception is dextrose given with insulin (hyperkalemia, DKA/HHS, high-dose insulin therapy).
Peripheral D25/D50: Osmolarity sits far above 900 mOsm/L. Labels prefer a central vein (D50 in age 2–11 yr: central only).
Alcohol use disorder or malnutrition: thiamine deficiency: give thiamine before, with or after dextrose, in any order or together. The one rule: never delay dextrose to give thiamine first.
Acute stroke or brain injury: correct the hypoglycemia first. Then avoid hyperglycemia.
Fluid or sodium disorders: long infusions can cause hyponatremia and fluid overload in children, older adults, and patients with heart or kidney failure or SIADH.
Sulfonylurea or long-acting insulin: the drug outlasts the bolus, so expect recurrence.

Hold / Reassess If

Patient alert and glucose ≥70 mg/dL: stop boluses and feed
Glucose >180 mg/dL during sulfonylurea treatment: reduce dextrose (the overshoot drives insulin release, and rebound follows)
Pain, swelling or blanching at the IV site: stop the push or infusion immediately
Headache, vomiting, confusion or falling Na⁺ during a prolonged infusion: stop and check Na⁺

Extravasation: Dextrose this concentrated can blister and destroy the tissue around the vein. Never push D50 into a small or doubtful peripheral line. Use D10 if you have it.

Adverse Effects & Toxicity

Common

Hyperglycemia: after a full 25 g D50 bolus, overshoot is common
Phlebitis and injection-site pain: it gets worse as the concentration climbs
Electrolyte shifts: low K⁺ and phosphate with prolonged use or insulin
Hyponatremia: with prolonged infusions
Vein thrombosis and catheter infection: the label lists them among the most common reactions

Serious / Life-Threatening

Effect	Recognition	Management
Extravasation injury	Pain, swelling, blistering, pale or dusky skin at the site	Stop; follow the institutional extravasation protocol; document the site and volume
Rebound hypoglycemia	Recurrent confusion or sweating; repeat glucose low, often after an overshoot	Bolus again, start an infusion, feed; octreotide if a sulfonylurea is involved
Hyperglycemia, hyperosmolar state	Confusion, polyuria, glucose very high after rapid or prolonged dosing	Stop dextrose; recheck; insulin if severe and persistent
Hyponatremic encephalopathy	Headache, nausea, vomiting, lethargy, seizure during prolonged infusion	Stop; urgent Na⁺; treat per hyponatremia protocol
Fluid overload	Crackles, edema, falling SpO₂	Slow or stop; switch to a more concentrated product via central line
Hypersensitivity	Rash, angioedema, bronchospasm, hypotension	Stop; treat as anaphylaxis
Wernicke encephalopathy	Confusion, ataxia, eye-movement palsy in thiamine-deficient patients	IV thiamine; continue glucose support

Overdose & Toxicity Management

Signs: hyperglycemia, hyperosmolality, dilutional hyponatremia and volume overload. Usually a pump or concentration error is behind it.
Immediate management: stop the infusion. Check glucose, Na⁺, K⁺ and fluid status. Give insulin only for severe persistent hyperglycemia. Treat CNS, respiratory and cardiovascular effects.
Antidote: none. For the cause of the hypoglycemia, see insulin and glucagon. Sulfonylurea toxicity needs octreotide.
Aluminum: D50 contains up to 600 mcg/L aluminum (Hospira 50% label). Prolonged use risks toxicity in children with immature or impaired kidney function, and in adults with kidney impairment. The label does not approve D50 under age 2 yr.

Monitoring

Parameter	When / How Often	Target / Act If
Clinical: mental status, GCS	After each D10 step or bolus	Not alert after the 25 g field max: look for another cause (stroke, overdose, sepsis, postictal) and transport
Laboratory: glucose (adult)	Before treatment, 15 min after, then until stable above 70 mg/dL	Glucose still <70 mg/dL: repeat treatment; persistent cases: infusion to 100–200 mg/dL
Laboratory: glucose after insulin for hyperkalemia	Before the dose, then every 30 min for 2 hr and hourly to at least 6 hr (0, 30, 60, 90, 120, 180, 240, 300, 360 min)	<70 mg/dL: treat; extend beyond 6 hr if high risk (repeat doses); risk highest in kidney failure, low weight, older age, no diabetes
Laboratory: glucose in sulfonylurea or long-acting insulin overdose	Frequently while on dextrose or octreotide	Observe at least 12 hr after both stop; any recurrence: bolus, then octreotide
Laboratory: glucose (neonate)	Within 30 min of each intervention, then until stable	Treatment target per NICU protocol (CPS: ≥2.6 mmol/L [47 mg/dL] in the first 72 hr; ≥3.3 mmol/L [60 mg/dL] after 72 hr or with documented hyperinsulinism)
Laboratory: K⁺, phosphate	With insulin co-therapy and prolonged infusions	K⁺ falling below 3.5 mEq/L: replace per protocol, avoiding over-replacement when the drop is an insulin shift
Laboratory: Na⁺	Daily or more often during prolonged infusions	Na⁺ falling or neurologic symptoms: stop the infusion and reassess
Infusion Safety: IV site	Before, during and after every push; hourly on infusions	Pain, swelling or blanching: stop immediately
Infusion Safety: concentration and rate	At start, bag change and handoff	Product in hand matches the order in grams and percent; GIR recalculated in neonates

Interactions & Compatibility

Clinically Significant Interactions

Drug / Class	Effect	What To Do
Insulin	Dextrose offsets insulin-induced hypoglycemia; together they drive K⁺ and phosphate into cells	Monitor glucose for hours and K⁺; this pairing is deliberate in hyperkalemia and DKA
Sulfonylureas (glipizide, glyburide, glimepiride)	Dextrose stimulates insulin release, so boluses are followed by rebound	Correct, then octreotide; avoid prophylactic or excessive dextrose
SGLT2 inhibitors	Euglycemic DKA: DKA with glucose about 200 mg/dL (11.1 mmol/L) and prior diabetes	Add dextrose early, alongside insulin
Drugs that cause hyponatremia (diuretics, SSRIs, SNRIs, vasopressin analogs, some antiepileptics)	Higher risk of hyponatremia with prolonged dextrose infusions	Avoid prolonged infusions or monitor Na⁺ closely; the Hospira 50% label says to avoid use in patients with or at risk for hyponatremia
Acarbose	Blocks sucrose breakdown, so table sugar works poorly	Use pure glucose (oral), not sucrose-containing food

IV Compatibility

Give rescue doses through a patent line flushed with normal saline before and after.
Never infuse with blood products in the same set (pseudoagglutination).
Dextrose solutions are diluents for many drugs. Check each drug's label before mixing.
Verify with an institutional compatibility resource.

Special Populations

Pediatrics: D10 is safe at every age. It works as quickly as stronger solutions. D50 is not labeled under 2 yr, and at 2–11 yr it is central-only. See the Pediatric Dosing table.
Neonates: D10 in the field and for boluses. More concentrated solutions only under NICU protocol. Rapid or concentrated dextrose raises osmolality and the risk of intracranial hemorrhage in very low birth weight infants. Aluminum exposure adds risk with prolonged use.
Pregnancy: Not expected to cause developmental harm when used appropriately. Maternal hyperglycemia near delivery can cause neonatal hypoglycemia. That is why you avoid overshoot during labor. Treat maternal hypoglycemia promptly.
Lactation: There are no data on milk glucose levels or effects on the breastfed infant. Weigh the benefits of breastfeeding against the clinical need (label).
Older Adults: Infusions carry a higher risk of hyponatremia and fluid overload. Start them low. Hypoglycemia risk from insulin and sulfonylureas is highest at age 75 yr and older.
Renal Impairment: Insulin lasts longer here. That makes insulin-dextrose for hyperkalemia carry a higher and later hypoglycemia risk (incidence up to 33% in end-stage kidney disease). Check glucose for at least 6 hr, and extend monitoring when late hypoglycemia is likely, such as after repeat doses. Prolonged infusions risk volume overload and aluminum accumulation.
Hepatic Impairment: No dose adjustment. Glucagon depends on glycogen, and depleted glycogen makes it unreliable. IV dextrose is the rescue of choice, and infusion needs may be higher.
Obesity / Dosing Weight: Adult rescue doses are fixed grams, titrated to response. Pediatric doses use actual weight, up to the adult dose.
Alcohol Use Disorder or Malnutrition: Give thiamine in any order, or together with dextrose, and never delay dextrose for it. Glycogen stores are often depleted.
Insulin Pump Users: In an altered patient (GCS <15), stop, disconnect or remove the pump at the insertion site if the patient cannot take oral glucose and ALS (IV dextrose) is not available. Leave it connected and running if the patient can take oral glucose or is receiving IV dextrose.

Field & Transport Considerations

Scope: oral glucose at every level. IV dextrose at AEMT and above. Infusions are at RN and critical-care transport level. Varies by state and agency protocol.
Storage & Stability: 20–25°C (68–77°F). Avoid excessive heat and protect from freezing. Discard cloudy solution or a broken seal.
Carried Concentration: D10 bags and D50 syringes look nothing alike. Yet 50 mL of D10 is only 5 g. Say the grams aloud when giving and documenting.
Release Without Transport: NASEMSO model criteria, all required: repeat glucose above 80 mg/dL. Normal mental status with no focal neurologic signs. Insulin or metformin only (no sulfonylurea). Will eat a carbohydrate meal. Patient or legal guardian declines transport, and EMS clinicians agree transport is not indicated. A reliable adult stays. A clear cause. No major other symptoms (chest pain, shortness of breath, intoxication). Transport anyone who seized.
Infusions in Transport: a pump, with the concentration verified at handoff. Enough volume for the trip. Keep checking glucose, since sulfonylurea patients recur in transit.
Handoff Essentials: grams and concentration given, glucose before and after with times, mental status response, cause (insulin type, sulfonylurea, missed meal) and pump status.

Hypoglycemia Ladder by Provider Level

Hypoglycemia ladder (scope varies by state and agency protocol)
Provider Level	Alert, Can Swallow	Cannot Swallow / Altered
Bystander, EMR, EMT	Oral glucose 15–25 g (child 0.5–1 g/kg); recheck in 15 min	EMT: glucagon IM/IN per protocol; nothing by mouth
AEMT, Paramedic	Oral glucose, then a meal	D10 in 5–10 g steps IV/IO to max 25 g; glucagon if no IV access
Paramedic, CCT	As above	D10 or D50 per protocol, infusion for recurrence, octreotide per medical direction
ED, ICU, Transport RN	As above	Bolus plus infusion, octreotide, neonatal GIR management, hyperkalemia regimen

Clinical Pearls

Sulfonylureas rebound: Each dextrose bolus pushes the pancreas to release more insulin. Repeated boluses end up chasing lows that keep coming back. After the first correction, give octreotide and observe for at least 12 hr.

D10 is not a weaker rescue: In a randomized prehospital trial, small D10 steps restored full consciousness as fast as D50. They used less than half the glucose. Post-treatment glucose was lower.

Exam discriminator: glucagon vs dextrose: Glucagon works only if the liver has glycogen to release. It fails in alcohol use, starvation and liver failure. In sulfonylurea overdose, it stimulates insulin release. IV dextrose works regardless.

Every altered patient gets a glucose check: Stroke, seizure, intoxication or psychiatric illness: hypoglycemia can look like any of them. Get the glucose before you settle on a cause.

Hyperkalemia: the low comes late: Insulin keeps working after the dextrose runs out. Kidney failure stretches that window. Glucose alone does not reliably lower K⁺, and it can raise it.

Euglycemic DKA: An SGLT2 inhibitor patient can be in DKA with a near-normal glucose. Add dextrose early, next to the insulin, so the insulin keeps working.

Feed after waking: Ongoing insulin or sulfonylurea action keeps pulling glucose down unless the patient eats. Once awake and able to swallow, give more carbohydrate as a meal or snack.

Pharmacology

Mechanism of Action

Exogenous glucose → restores plasma glucose → reverses neuroglycopenia (confusion, seizure, coma).
Supplies 3.4 kcal/g. Oxidized to CO₂ and water.
Raises insulin secretion in patients with working β-cells → rebound after sulfonylureas or overshoot.
Hypertonic solutions pull water from the vein wall → phlebitis, thrombosis and extravasation injury.

Pharmacokinetics

Route	Onset	Peak	Duration
IV, IO	Glucose rises within minutes; median 8 min to full GCS 15	At the end of the bolus	Variable: depends on ongoing insulin or sulfonylurea effect and glycogen stores
PO (oral glucose)	Recheck at 15 min	—	Short; follow with a meal

Half-life: not applicable. Tissues take up glucose and use or store it.
Metabolism: glycolysis and oxidation to CO₂ and water. Storage as glycogen.
Elimination: glucose spills into urine when hyperglycemia is marked, causing osmotic diuresis.

Names & Classification

Generic Name: Dextrose (D-glucose monohydrate) injection, USP: 10%, 25%, 50%
Brand Names: Sold generically (e.g., Hospira Ansyr syringes); called glucose 10% or 50% outside the US
Pharmacologic Class: Carbohydrate solution (monosaccharide)
Therapeutic Class: Antihypoglycemic agent; caloric agent; adjunct to insulin therapy
Controlled Substance: Not controlled
ISMP High-Alert: Yes: ISMP high-alert medication (dextrose, hypertonic, 20% or greater: D25, D50); D10 is not on the list
Look-Alike / Sound-Alike: No ISMP name pair commonly reported; the hazard is concentration confusion (D5W, D10W, D25W, D50W) and mL-for-gram errors

References

Hospira, Inc. (2026). Dextrose Injection (50%) [prescribing information] (revised January 2026). DailyMed, National Library of Medicine. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=4ed365da-4e62-4329-c1b9-c197ab4fb6e1. Hospira, Inc. (2025). Dextrose Injection (25%) [prescribing information] (revised July 2025). DailyMed, National Library of Medicine. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=672264e3-9709-4bba-2a9d-12bf70c7396a
American Diabetes Association Professional Practice Committee for Diabetes. (2026). 6. Glycemic goals, hypoglycemia, and hyperglycemic crises: Standards of Care in Diabetes—2026. Diabetes Care, 49(Suppl 1), S132–S149. https://doi.org/10.2337/dc26-S006
Umpierrez, G. E., Davis, G. M., ElSayed, N. A., Fadini, G. P., and colleagues. (2024). Hyperglycemic crises in adults with diabetes: a consensus report. Diabetes Care, 47(8), 1257–1275. https://doi.org/10.2337/dci24-0032
National Association of State EMS Officials. (2022). National Model EMS Clinical Guidelines, Version 3.0: Hypoglycemia (pp. 84–87). NASEMSO Medical Directors Council. https://hhs.iowa.gov/media/198/download
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