A Guide for Persons with Diabetes: How to Handle Severe Hypoglycemia Hypoglycemia, commonly known as low blood sugar, is a frequent complication for i...

A Guide for Persons with Diabetes: How to Handle Severe Hypoglycemia

Hypoglycemia, commonly known as low blood sugar, is a frequent complication for individuals managing diabetes. While mild to moderate episodes can often be self-treated with quick-acting carbohydrates, severe hypoglycemia requires immediate intervention to prevent serious health consequences. This guide aims to provide a comprehensive overview of severe hypoglycemia, focusing on recognition, treatment, and prevention strategies for individuals with diabetes and their caregivers.

Understanding Severe Hypoglycemia

Severe hypoglycemia is a state of extremely low blood glucose levels, typically defined as a blood sugar reading below 70 mg/dL (3.9 mmol/L), that results in cognitive impairment or physical incapacitation. In such cases, the individual may be unable to self-treat, necessitating assistance from another person. Understanding the causes and symptoms is critical for timely and effective management.

Causes of Severe Hypoglycemia

Excessive Insulin Dose: Incorrect insulin dosing is a primary cause, especially when not aligned with dietary intake or physical activity.
Missed or Delayed Meals: Skipping meals or significantly delaying them can lead to blood sugar dropping too low, especially for those on insulin or certain oral medications.
Intense Exercise: Unplanned or strenuous physical activity can rapidly deplete glucose stores, causing a hypoglycemic episode.
Alcohol Consumption: Alcohol can impair the liver's ability to release glucose into the bloodstream, particularly when consumed without food.
Certain Medications: Some diabetes medications, such as sulfonylureas, are more likely to cause hypoglycemia than others.
Kidney or Liver Disease: Impaired kidney or liver function can affect how medications are metabolized, increasing the risk of hypoglycemia.

Symptoms of Severe Hypoglycemia

Recognizing the signs and symptoms of severe hypoglycemia is crucial for prompt treatment. Symptoms can vary from person to person, but common indicators include:

| Symptom Category | Specific Symptoms | |------------------|-------------------------------------------------------| | Cognitive | Confusion, difficulty concentrating, disorientation, slurred speech, loss of consciousness | | Neurological | Seizures, convulsions | | Behavioral | Irritability, combativeness, unusual behavior | | Physical | Weakness, incoordination, sweating, rapid heartbeat |

It’s important to note that some individuals may experience hypoglycemia unawareness, where they don’t recognize the warning signs of low blood sugar. This condition increases the risk of severe episodes and requires specialized management strategies, which we'll discuss later.

Immediate Treatment of Severe Hypoglycemia

When someone is experiencing severe hypoglycemia, prompt action is crucial to raise their blood sugar levels and prevent potential harm. Since the person is likely unable to self-treat due to cognitive impairment or loss of consciousness, assistance from someone else is necessary.

Step-by-Step Guide for Treating Severe Hypoglycemia

Confirm the Condition: If possible, check the person’s blood glucose level with a glucose meter to confirm hypoglycemia. However, if a meter is unavailable or the person is unresponsive, assume it’s hypoglycemia and proceed with treatment.
Administer Glucagon: Glucagon is a hormone that stimulates the liver to release stored glucose into the bloodstream, rapidly raising blood sugar levels. It is typically administered via injection and is available in pre-filled syringes or nasal sprays.
- Injection:
  - Locate the glucagon emergency kit.
  - Follow the kit's instructions for mixing and drawing up the glucagon.
  - Inject the glucagon into the thigh, arm, or buttock.
  - The typical adult dose is 1 mg. Children's doses vary by weight (consult the product information or a healthcare provider).
- Nasal Spray:
  - Remove the nasal spray device from its packaging.
  - Insert the tip of the device into one nostril.
  - Press the plunger to deliver the dose.
  - There is usually a fixed dose per device.
Call for Emergency Medical Assistance: After administering glucagon, immediately call emergency services (911 in the United States) or your local emergency number. Explain the situation and that the person has diabetes and received glucagon for severe hypoglycemia.
Monitor and Observe: After administering glucagon, monitor the person's condition closely. They should start to regain consciousness and improve within 5 to 15 minutes.
Related reading: Is Your Normal Blood Sugar Level Sabotaging Your Health
Provide Food Once Conscious: Once the person regains consciousness and is able to swallow, give them a fast-acting source of carbohydrates, such as juice, glucose tablets, or regular (non-diet) soda, followed by a longer-acting source of carbohydrates and protein, such as crackers with peanut butter or a cheese sandwich. This helps stabilize blood sugar levels.
Document the Episode: Record the time of the episode, symptoms observed, treatment given (glucagon dose, carbohydrate source), and the person’s response. Share this information with their healthcare provider for further evaluation and adjustments to their diabetes management plan.

Situations Where Glucagon May Not Be Effective

Glucagon relies on the liver having stored glucose to release. Therefore, glucagon may be less effective in individuals who:

Have exhausted their glycogen stores due to prolonged fasting or malnutrition.
Have liver disease (e.g., cirrhosis).
Have recently consumed large amounts of alcohol.

In these situations, intravenous glucose administered by medical professionals may be necessary to raise blood sugar levels.

Prevention Strategies for Severe Hypoglycemia

Preventing severe hypoglycemia is crucial for maintaining overall health and well-being. A proactive approach involving diligent monitoring, education, and communication with healthcare providers is key.

Blood Glucose Monitoring and Management

Regular Monitoring: Consistent blood glucose monitoring is the cornerstone of diabetes management. Individuals using insulin should check their blood sugar levels multiple times a day, particularly before meals, before bedtime, and before and after exercise.
Continuous Glucose Monitoring (CGM): CGM devices provide real-time glucose readings and trend information, alerting users to impending highs and lows. Many modern CGMs can communicate directly with insulin pumps to automatically adjust insulin delivery (hybrid closed-loop systems). These systems can significantly reduce the risk of severe hypoglycemia.
Adjust Insulin Doses: Work closely with a healthcare provider or certified diabetes educator (CDE) to adjust insulin doses based on blood glucose patterns, dietary intake, and physical activity. Be particularly mindful of basal and bolus insulin adjustments.

Education and Awareness

Diabetes Education Programs: Participating in a comprehensive diabetes education program is invaluable. These programs provide in-depth knowledge about diabetes management, including hypoglycemia prevention and treatment.
Educate Family and Friends: Teach family members, friends, and coworkers how to recognize the signs of hypoglycemia and how to administer glucagon. Ensure they know where the glucagon kit is located and how to use it correctly.
Wear Medical Identification: Wear a medical ID bracelet or necklace that indicates you have diabetes and, if possible, includes emergency contact information. This is critical for emergency responders in case you’re unable to communicate.

Meal Planning and Timing

Consistent Meal Schedules: Eating meals and snacks at consistent times each day helps maintain stable blood glucose levels.
Carbohydrate Counting: Learn how to accurately count carbohydrates in your meals and snacks to match your insulin doses appropriately.
Pre-Exercise Snacks: Consume a carbohydrate-rich snack before engaging in physical activity, especially if you are on insulin. The amount of carbohydrate needed will depend on the intensity and duration of the exercise.

Alcohol Consumption

Drink in Moderation: If you choose to drink alcohol, do so in moderation and always consume it with food.
Monitor Blood Sugar: Check your blood sugar levels frequently when drinking alcohol, as alcohol can affect glucose levels for many hours.
Avoid Drinking on an Empty Stomach: Never drink alcohol on an empty stomach, as this can increase the risk of hypoglycemia.

Specific Strategies for Hypoglycemia Unawareness

As mentioned earlier, hypoglycemia unawareness is a dangerous condition where individuals no longer experience the warning signs of low blood sugar. People with this condition are at a higher risk of severe hypoglycemia. Specific strategies to address hypoglycemia unawareness include:

Strict Avoidance of Hypoglycemia: Avoid any episodes of hypoglycemia for several weeks. This can help restore the body’s ability to recognize low blood sugar levels. Discuss with your doctor how to safely elevate your target blood glucose range temporarily.
Continuous Glucose Monitoring (CGM): CGM systems can provide alerts when blood sugar levels are dropping, even if you don’t feel the symptoms. Set the alerts to a slightly higher threshold to give you more time to react.
Regular Blood Glucose Checks: Frequent blood glucose monitoring throughout the day and night can help you identify patterns and prevent lows.
Education and Support: Work with a diabetes educator or healthcare provider to develop a personalized management plan. Joining a support group can provide valuable insights and emotional support.

Practical Tips for Carrying and Managing Glucagon

Having glucagon readily available and knowing how to use it is paramount for individuals at risk of severe hypoglycemia. Here are some practical tips:

Glucagon Kit Accessibility

Carry Glucagon: Always carry a glucagon kit with you, especially when traveling or engaging in activities where hypoglycemia is a risk.
Multiple Locations: Keep glucagon kits in multiple locations, such as at home, at work, in your car, and in your travel bag.
Inform Others: Ensure that family members, friends, and coworkers know where the glucagon kits are located and how to administer glucagon.

Storage and Expiration

Check Expiration Dates: Regularly check the expiration date on your glucagon kits and replace them before they expire.
Proper Storage: Store glucagon kits in a cool, dry place, away from direct sunlight and extreme temperatures.
Avoid Refrigeration: Do not refrigerate glucagon, as this can damage the medication.

Practice and Training

Review Instructions: Regularly review the instructions for using your glucagon kit.
Practice Injection Technique: If using injectable glucagon, practice the injection technique with a trainer device or with guidance from a healthcare professional.
Role-Playing: Simulate a hypoglycemic emergency with family members or friends to practice administering glucagon in a calm and organized manner.

Using Newer Glucagon Formulations

Newer formulations of glucagon such as nasal sprays and pre-mixed auto-injectors offer easier administration with less preparation. Familiarize yourself with these if they are prescribed.

When to Seek Professional Medical Advice

While glucagon is an effective treatment for severe hypoglycemia, it is not a substitute for professional medical care.

Situations Requiring Emergency Medical Assistance

Unresponsiveness After Glucagon: If the person does not regain consciousness or improve within 15 minutes after receiving glucagon, seek immediate medical attention.
Repeated Episodes: Frequent episodes of severe hypoglycemia warrant a thorough evaluation by a healthcare provider.
Pregnancy: Pregnant women experiencing severe hypoglycemia require immediate medical attention.
Underlying Medical Conditions: Individuals with other underlying medical conditions, such as heart disease, should seek immediate medical care for severe hypoglycemia.

Long-Term Management and Follow-Up

Review Diabetes Management Plan: After an episode of severe hypoglycemia, review your diabetes management plan with your healthcare provider. This may involve adjusting insulin doses, meal plans, or exercise routines.
Identify Underlying Causes: Work with your healthcare provider to identify the underlying causes of the hypoglycemic episode and implement strategies to prevent future occurrences.
Consider Psychological Impact: Hypoglycemia can have a significant psychological impact, leading to anxiety and fear. Consider seeking support from a mental health professional specializing in diabetes.

By understanding the causes, symptoms, treatment, and prevention strategies for severe hypoglycemia, individuals with diabetes and their caregivers can effectively manage this potentially life-threatening condition. Consistent monitoring, education, and proactive communication with healthcare providers are essential for minimizing the risk of severe hypoglycemic episodes and promoting overall well-being.