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Date/Time:______Allergies______Hgt_____ Wt______ED PEDS Suspected Hypoglycemia General For Pediatric patients with altered mental status or cardio-respiratory distress, AND POC blood sugar < 70 gfedc Other Patient Care Insert/Maintain IV gfedc 2 Sites Required : No gfedc Other Medications Communication gfedc Critical Blood Sample needs to be drawn BEFORE any D25W is given; DO NOT GIVE DOSE UNTIL LABS ARE DRAWN gfedc Dextrose 25% intravenous solution IV Push 0.5 gm/kg ONCE Inj Recheck POC blood sugar in 15 minutes; if BS < 70 and patient symptomatic call physician gfedc Dextrose 25% intravenous solution IV Push 1 gm/kg ONCE Inj Recheck POC blood sugar in 15 minutes; if BS < 70 and patient symptomatic call physician Lab Draw Instructions for Nursing gfedc Recheck POC blood sugar in 15 minutes after giving dextrose injection; if BS < 70 and patient symptomatic call physician NURSE TO PLACE INDIVIDUAL LAB ORDER AT APPROPRIATE TIME gfedc Other Laboratory PATIENT WITH WEIGHT OF 80 POUNDS OR LESS: PEDS Hypoglycemia Panel gfedc Blood Priority 2 ; For the Critical Blood Sample, draw 2 x 4 mls in two red- top tubes Lactic Acid gfedc Blood Priority 2 ; 1 ml in a gray-top tube; placed in ice Ammonia gfedc Blood Priority 2 ; 1 ml in a lavender-top tube; placed in ice PATIENT WITH WEIGHT GREATER THAN 80 POUNDS: Basic Metabolic Panel Random Glucose gfedc Blood Priority 2 Insulin Level gfedc Blood Priority 2 C Peptide gfedc Blood Priority 2 Growth Hormone Level

ED PEDS Suspected Hypoglycemia Page 1 of 2 Wellspan Health Patient Demographics gfedc Gettysburg Hospital gfedc York Hospital gfedc WellSpan Surgical and Rehabilitation Hospital

Physician Signature______Date/Time:______Allergies______Hgt_____ Wt______gfedc Blood Priority 2 Cortisol Level gfedc Blood Priority 2 Very Long Chain Fatty Acids gfedc Blood Priority 2 Beta Hydroxybutyrate Level gfedc Blood Priority 2 Ketone Serum gfedc Blood Priority 2 Lactic Acid gfedc Blood Priority 2 gray-top tube; placed in ice Ammonia gfedc Blood Priority 2 lavender-top tube; placed in ice Revised: 3/8/2017 gfedc Other

ED PEDS Suspected Hypoglycemia Page 2 of 2 Wellspan Health Patient Demographics gfedc Gettysburg Hospital gfedc York Hospital gfedc WellSpan Surgical and Rehabilitation Hospital

Physician Signature______

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