Skip to content

Trauma Glycemic Control Protocol

Division of Acute Care Surgery

1. Initial Glycemic Assessment

Is the patient a known diabetic?

  • No:
  • If blood glucose (BG) ≤ 150 mg/dL → No further action

  • If BG > 150 mg/dL:

    • Check hemoglobin A1c (HbA1c)
    • Initiate correctional insulin using a sliding scale (SSI)
    • If HbA1c > 6.5%:
    • Add type 2 diabetes mellitus (T2DM) to the problem list
    • Initiate basal insulin: Glargine 0.15 units/kg/day
    • Consult Endocrinology

  • Yes (Established diabetes):
    Proceed to Section 2.

2. Management in Known Diabetics

A. Insulin-Dependent Diabetes Mellitus (IDDM)

  • Check HbA1c
  • Initiate:
  • Sliding Scale Insulin (SSI)
  • Basal insulin: Resume 50% of home Glargine dose
  • If BG > 200 mg/dL:
  • If HbA1c > 6.5%:
    • Confirm diagnosis on problem list (if not already present)
    • Increase Glargine to 0.15 units/kg/day
    • Consult Endocrinology

B. Non–Insulin-Dependent Diabetes Mellitus (NIDDM)

  • Check HbA1c
  • Initiate:
  • Sliding Scale Insulin (SSI)
  • Basal insulin: Glargine 0.15 units/kg/day

3. Persistent Hyperglycemia

If BG remains > 180 mg/dL despite SSI and basal insulin:

  • Add prandial insulin (Lispro) with meals
    or
  • Initiate scheduled Lispro q4–6h in patients receiving continuous enteral nutrition

4. General Principles and Safety Considerations

  • Avoid SSI monotherapy in type 2 diabetes mellitus (T2DM)
  • Continue basal insulin even if the patient is NPO
  • Ensure the hypoglycemia protocol is activated with all insulin orders
  • Endocrinology consultation is recommended for:
  • Type 1 diabetes mellitus (T1DM)
  • Patients using insulin pumps
  • Newly diagnosed T2DM (HbA1c > 6.5%)
  • Known diabetics with HbA1c > 9%

Use caution in:

  • Patients with chronic kidney disease (CKD)
  • Older adults
  • Patients with significant fluid shifts
  • Consider pharmacy consultation in these cases

5. Discontinuation of Glycemic Monitoring

Consider stopping BG checks and insulin therapy if ALL criteria are met:

  • BG remains ≤ 150 mg/dL
  • Patient has met tube feeding goal for > 24 hours
  • Patient is off vasopressors

Insulin Infusion Protocol (TICU Only)

6. Initiation Criteria

Consider initiating an insulin infusion per TICU protocol if:

  • Two consecutive BG readings ≥ 250 mg/dL

Nutritional Support Required

Ensure a glucose source is provided via one of the following:

  • D10 infusion at 30 mL/hr
  • D5LR or D5NS at ≥ 50 mL/hr
  • Enteral nutrition at ≥ 50% of target goal rate
  • Parenteral nutrition (PN) infusing

7. Transition Off Insulin Infusion

When to discontinue insulin infusion:

  • Infusion rate is ≤ 5 units/hr for ≥ 4 hours
  • Patient is receiving a consistent source of nutrition

Transition strategy:

  1. Discontinue insulin infusion
  2. Initiate Sliding Scale Insulin per Burn/Trauma order set
  3. Calculate total insulin administered over the past 24 hours
  4. Administer 70% of that total daily dose:
  5. 50% as basal insulin (e.g., Glargine)
  6. Continue SSI
  7. Add prandial insulin (Lispro) q4–6h or with meals if needed

8. References

  1. Yendamuri S, et al. Admission hyperglycemia as a prognostic indicator in trauma. J Trauma. 2003; 55:33–38.
  2. Laird A, et al. Relationship of early hyperglycemia to mortality in trauma patients. J Trauma. 2004; 56:1058–1062.
  3. Sung J, et al. Admission hyperglycemia is predictive of outcome in critically ill trauma patients. J Trauma. 2005; 59:80–83.
  4. Van den Berghe G, et al. Intensive insulin therapy in critically ill patients. N Engl J Med. 2001; 345:1359–1367.
  5. NICE-SUGAR Study Investigators. Intensive vs. conventional glucose control in critically ill patients. N Engl J Med. 2009; 360:1283–1297.
  6. Jacobi J, et al. Guidelines for the use of insulin infusion in critically ill patients. Crit Care Med. 2012; 40:3251–3276.
  7. Mowery NT, et al. Severe hypoglycemia is not an independent predictor of death after trauma. J Trauma. 2010; 68:342–347.
  8. Mowery NT, et al. Duration of intensive insulin therapy predicts hypoglycemia. World J Surg. 2011; 36:270–277.
  9. Krinsley J, et al. Glycemic variability as a predictor of mortality in critically ill patients. Crit Care Med. 2008; 36:3008–3013.
  10. Kauffmann RM, et al. Balanced nutrition protects against hypoglycemia in surgical ICU patients. JPEN. 2011; 35:686–694.
  11. Bode BW, et al. IV insulin infusion: indications, methods, and transition to subQ insulin. Endocr Pract. 2004; 10(2):71–80.

9. Revision History

  • January 2020
  • March 2023

10. Revision Team

  • Michael Derickson, MD
  • Jill Streams, MD — Trauma PI Director
  • Bradley Dennis, MD — Trauma Medical Director
  • Caroline Banes, DNP, ACNP-BC
  • Kayla Harding, MSN, AGACNP
  • Leanne Atchison, PharmD