A Guide to Severe Hypoglycemia for Persons with Diabetes and Their Families Hypoglycemia, or low blood sugar, is a common complication of diabetes tre...

A Guide to Severe Hypoglycemia for Persons with Diabetes and Their Families

Hypoglycemia, or low blood sugar, is a common complication of diabetes treatment, particularly for those using insulin or certain oral medications. While mild to moderate hypoglycemia can often be managed independently, severe hypoglycemia is a serious condition requiring immediate assistance. This guide aims to provide individuals with diabetes and their families with essential information on recognizing, preventing, and treating severe hypoglycemia.

Why This Matters: Understanding severe hypoglycemia is crucial for maintaining the safety and well-being of individuals with diabetes. Preparedness and knowledge can significantly reduce the risks associated with this condition, improving overall diabetes management and quality of life.

Understanding Severe Hypoglycemia

Severe hypoglycemia is defined as a low blood sugar level that causes significant mental or physical impairment, requiring assistance from another person to treat. This usually means the individual is unable to self-treat due to confusion, loss of consciousness, seizures, or other serious symptoms.

What Happens During Severe Hypoglycemia?

When blood glucose levels drop too low (typically below 70 mg/dL, but the specific threshold can vary), the brain doesn’t receive enough energy to function properly. This can lead to:

Confusion and disorientation
Slurred speech
Loss of coordination
Seizures
Unconsciousness
Coma

These symptoms can be frightening and dangerous, highlighting the need for prompt and effective intervention.

Key Differences Between Mild, Moderate, and Severe Hypoglycemia:

Understanding these distinctions allows for quicker and more appropriate responses at each stage.

Recognizing the Signs and Symptoms

Early recognition of hypoglycemia is vital for preventing it from progressing to a severe state. Both individuals with diabetes and their families should be familiar with the warning signs. These can be categorized into adrenergic (autonomic) and neuroglycopenic symptoms.

Adrenergic Symptoms: These are caused by the body's release of epinephrine (adrenaline) as it tries to raise blood sugar. They include:

Shakiness
Sweating
Rapid heartbeat (palpitations)
Anxiety or nervousness
Hunger
Tingling around the mouth

Neuroglycopenic Symptoms: These occur when the brain is deprived of glucose. They are more indicative of a more severe drop in blood sugar and include:

Confusion
Difficulty concentrating
Slurred speech
Blurred vision
Weakness
Drowsiness
Headache
Seizures
Loss of consciousness

Important Note: Some individuals, especially those with longstanding diabetes or frequent hypoglycemic episodes, may experience hypoglycemia unawareness, meaning they don't feel the early warning signs. This significantly increases the risk of severe hypoglycemia. Regularly monitoring blood glucose and working closely with a healthcare provider are crucial in these cases.

Causes and Risk Factors of Severe Hypoglycemia

Several factors can contribute to severe hypoglycemia. Understanding these causes can help in prevention.

Excessive Insulin Dosage: Taking too much insulin relative to food intake or activity level is a primary cause.
Missed or Delayed Meals: Skipping meals or delaying eating after taking insulin can lead to low blood sugar.
Increased Physical Activity: Exercise increases glucose utilization, and without adjusting insulin or increasing carbohydrate intake, hypoglycemia can occur.
Alcohol Consumption: Alcohol can impair the liver's ability to release glucose, particularly when consumed without food.
Certain Medications: Some diabetes medications, particularly sulfonylureas (e.g., glimepiride, glyburide), increase insulin secretion and can cause hypoglycemia. Other non-diabetes medications can also impact blood glucose.
Kidney or Liver Disease: Impaired kidney or liver function can affect how the body processes insulin and glucose, increasing the risk of hypoglycemia.
Illness: Infections or other illnesses can affect blood sugar levels and insulin requirements.
Gastroparesis: Delayed stomach emptying can lead to unpredictable absorption of glucose from food.
Inconsistent Carbohydrate Intake: Varying the amount of carbohydrates consumed at meals can make it difficult to match insulin doses.

Risk Factors Specific to Severe Hypoglycemia:

History of severe hypoglycemia: Individuals who have experienced severe hypoglycemia are at higher risk for future episodes.
Hypoglycemia unawareness: As mentioned above, the inability to recognize early warning signs significantly increases the risk.
Long-duration diabetes: The risk of hypoglycemia generally increases with the duration of diabetes due to declining insulin secretion or increased insulin sensitivity.
Tight glycemic control: While aiming for tight blood sugar control is important, overly aggressive targets can increase the risk of hypoglycemia.

Responding to Severe Hypoglycemia: A Step-by-Step Guide

When someone experiences severe hypoglycemia, prompt and correct action is essential. Here's a step-by-step guide for family members and caregivers:

Assess the Situation: Check for signs of severe hypoglycemia such as unresponsiveness, confusion, seizures, or loss of consciousness. If in doubt, assume it is hypoglycemia.
Do NOT Give Food or Drink: If the person is unconscious or unable to swallow safely, do not attempt to give them anything by mouth. This can lead to choking or aspiration.
Administer Glucagon (If Available):
- What is Glucagon? Glucagon is a hormone that stimulates the liver to release stored glucose into the bloodstream, rapidly raising blood sugar levels. It is available as an injection or a nasal spray.
- How to Administer Glucagon Injection:
  - Check the expiration date: Ensure the glucagon kit hasn't expired.
  - Prepare the injection: Follow the instructions included with the kit. Typically, this involves mixing the glucagon powder with the diluent.
  - Inject the glucagon: Inject into the thigh, arm, or buttock. It can be given through clothing if necessary.
- How to Administer Nasal Glucagon:
  - Check the expiration date: Ensure the nasal glucagon hasn't expired.
  - Administer the dose: Insert the device into one nostril and press the plunger to deliver the dose.
- Call for Emergency Medical Assistance (911 or Local Equivalent): Even if glucagon is administered and the person appears to be recovering, it's crucial to call for emergency medical assistance. This is because the effects of glucagon are temporary, and the underlying cause of the hypoglycemia needs to be addressed. Additionally, some individuals may not respond adequately to glucagon.
- Monitor the Person: Stay with the person and monitor their breathing and level of consciousness until medical help arrives. If they start to vomit, turn them onto their side to prevent choking.
- Provide Information to Medical Personnel: When paramedics or other medical professionals arrive, provide them with information about the person's diabetes, medications, any recent events that might have contributed to the hypoglycemia (e.g., missed meal, exercise), and whether glucagon was administered.
- After Recovery: Once the person is fully conscious and able to eat and drink, offer them a carbohydrate-rich snack, such as crackers, fruit juice, or a glucose tablet, to replenish their blood sugar levels.

Important Considerations for Glucagon:

Glucagon does not work if the person's glycogen stores are depleted: This can occur with prolonged fasting, severe liver disease, or after intense exercise.
Side effects of glucagon can include nausea and vomiting.
Teach family members and caregivers how to administer glucagon: This is a vital skill for anyone who regularly interacts with a person with diabetes.
Always keep glucagon readily available: Store glucagon kits in accessible locations at home, work, and when traveling.
Check the expiration date regularly and replace expired kits.

Training and Resources:

American Diabetes Association (ADA): Provides comprehensive information on diabetes management, including hypoglycemia.
JDRF (formerly Juvenile Diabetes Research Foundation): Offers resources and support for individuals with type 1 diabetes and their families.
Endocrinologist or Certified Diabetes Educator (CDE): These healthcare professionals can provide personalized education and guidance on hypoglycemia prevention and treatment.

Preventing Severe Hypoglycemia: Proactive Strategies

Prevention is the best approach to severe hypoglycemia. Here are several strategies to minimize the risk:

Regular Blood Glucose Monitoring: Frequent blood glucose monitoring, especially before meals, bedtime, and exercise, allows for timely adjustments in insulin dosage or carbohydrate intake. Continuous Glucose Monitors (CGMs) can be particularly helpful, as they provide real-time glucose readings and alerts for impending low blood sugar.
Consistent Meal Timing and Carbohydrate Intake: Maintaining a consistent meal schedule and carbohydrate intake at each meal helps to stabilize blood sugar levels and reduce the risk of hypoglycemia.
Careful Insulin Dosage Adjustment: Work closely with your healthcare provider to adjust insulin dosages based on blood glucose levels, food intake, and activity levels. Consider using insulin pumps or pens with bolus calculators to improve insulin dosing accuracy.
Planning for Exercise: Exercise can significantly lower blood sugar levels. Before exercising, check your blood glucose level and consume extra carbohydrates if needed. Reduce your insulin dose for the activity, as directed by your healthcare provider. Carry a fast-acting source of glucose with you during exercise in case your blood sugar drops too low.
Alcohol Awareness: If you choose to consume alcohol, do so in moderation and always with food. Be aware that alcohol can impair your ability to recognize the symptoms of hypoglycemia.
Medication Review: Regularly review all medications with your healthcare provider, including both prescription and over-the-counter drugs. Some medications can interact with diabetes medications and increase the risk of hypoglycemia.
Communication with Healthcare Team: Maintain open communication with your healthcare team about any concerns or challenges you're experiencing with hypoglycemia. They can provide personalized advice and adjust your treatment plan as needed.
Educate Family and Friends: Teach family members, friends, and coworkers about diabetes, hypoglycemia, and how to administer glucagon. This can be life-saving in an emergency.
Wear a Medical Alert Identification: Wearing a medical ID bracelet or necklace that identifies you as having diabetes can alert first responders to your condition in case of an emergency.
Consider Emerging Technologies: Explore newer technologies like automated insulin delivery (AID) systems, also known as artificial pancreas systems, which can automatically adjust insulin delivery based on real-time glucose levels, potentially reducing the risk of hypoglycemia.

Table: Strategies to Prevent Hypoglycemia Based on Different Activities:

| Activity | Prevention Strategy | | :------------- | :------------------------------------------------------------------------------------------------------------ | | Eating | Consistent meal timing; carb counting; pre-meal glucose checks and insulin adjustments. | | Exercising | Check glucose before, during, and after; reduce insulin or increase carbs; carry fast-acting glucose. | | Drinking Alcohol | Consume with food; monitor glucose; limit intake; inform others you have diabetes and know hypoglycemia signs | | Traveling | Pack extra supplies; adjust insulin for time zone changes; monitor glucose frequently. | | During illness | Check glucose more often; adjust insulin as directed by doctor; stay hydrated; consider liquid carbohydrate sources |

By diligently implementing these preventative strategies, individuals with diabetes and their families can significantly reduce the risk of severe hypoglycemia and promote safer, healthier lives.