How to Handle Severe Hypoglycemia: An Emergency Step-by-Step Guide Severe hypoglycemia, or dangerously low blood sugar, is a critical medical conditio...

How to Handle Severe Hypoglycemia: An Emergency Step-by-Step Guide

Severe hypoglycemia, or dangerously low blood sugar, is a critical medical condition that can lead to seizures, loss of consciousness, and even death if not treated promptly. This guide provides a detailed, step-by-step approach to recognizing and managing severe hypoglycemia in an emergency situation. Whether you're a caregiver, family member, or friend of someone with diabetes, knowing how to respond can be life-saving. This comprehensive guide covers everything from identifying the symptoms to administering glucagon and seeking follow-up medical care.

Understanding Hypoglycemia and Its Severity

Hypoglycemia occurs when blood glucose levels drop too low, typically below 70 mg/dL (3.9 mmol/L). While mild to moderate hypoglycemia can usually be managed with oral glucose or simple carbohydrates, severe hypoglycemia requires immediate intervention. Recognizing the early signs of hypoglycemia can prevent it from escalating to a severe state.

Stages of Hypoglycemia:

Mild Hypoglycemia: Symptoms may include shakiness, sweating, dizziness, and hunger.
Moderate Hypoglycemia: Symptoms intensify, with confusion, irritability, and difficulty concentrating.
Severe Hypoglycemia: Characterized by disorientation, loss of consciousness, seizures, or inability to swallow.

Why Severe Hypoglycemia is an Emergency

Severe hypoglycemia is an emergency because the brain relies on glucose for energy. Without sufficient glucose, brain function can deteriorate rapidly, leading to:

Seizures: Uncontrolled electrical activity in the brain.
Loss of Consciousness: The person becomes unresponsive to stimuli.
Brain Damage: Prolonged hypoglycemia can cause irreversible brain damage.
Death: In extreme cases, severe hypoglycemia can be fatal.

Common Causes of Hypoglycemia

Understanding the common causes of hypoglycemia can help in prevention. Factors that can lead to low blood sugar include:

Excessive Insulin Dosage: Taking too much insulin in relation to food intake or activity level.
Skipped or Delayed Meals: Not eating enough or waiting too long between meals.
Intense Exercise: Physical activity can lower blood sugar, especially if not properly managed.
Alcohol Consumption: Alcohol can interfere with the liver's ability to release glucose into the bloodstream.
Certain Medications: Some medications, such as sulfonylureas, can increase insulin secretion and the risk of hypoglycemia.

By recognizing the severity and potential causes of hypoglycemia, you'll be better prepared to act quickly and effectively in an emergency situation.

Step 1: Recognize the Signs and Symptoms

Prompt recognition of severe hypoglycemia is the first critical step in managing the emergency. The signs and symptoms can vary from person to person, but some common indicators include:

Observable Symptoms:

Unconsciousness: The person is unresponsive and cannot be awakened.
Seizures: Involuntary muscle contractions and loss of awareness.
Difficulty Breathing: Shallow or labored breathing.
Pale or Clammy Skin: Skin feels cool and moist to the touch.
Erratic Behavior: Confusion, disorientation, or unusual behavior.
Inability to Swallow: The person cannot safely consume food or liquids.

Subtle Symptoms to Watch For:

Sometimes the symptoms of severe hypoglycemia can be subtle and easily overlooked. It's important to be vigilant and look for the following:

Marked Confusion: Sudden inability to understand or follow simple instructions.
Severe Weakness: Extreme fatigue or inability to move.
Slurred Speech: Difficulty speaking clearly.
Profuse Sweating: Excessive sweating without physical exertion.
Visual Disturbances: Blurred or double vision.

People with Diabetes May Also Report:

While a person experiencing severe hypoglycemia may not be able to communicate effectively, they may have mentioned experiencing the following symptoms before losing consciousness:

Intense Hunger: An overwhelming urge to eat.
Shakiness or Tremors: Uncontrollable shaking.
Rapid Heartbeat: Feeling like their heart is racing.
Anxiety or Nervousness: Feeling jittery or panicked.
Tingling Sensations: Numbness or tingling around the mouth or fingertips.

Example Scenario:

Imagine you're visiting a friend who has type 1 diabetes. You notice they are unusually quiet and seem disoriented. They try to speak, but their words are slurred, and they start to sweat profusely. Recognizing these symptoms as potential signs of severe hypoglycemia, you know it's time to act quickly.

Note: If you are unsure whether someone is experiencing hypoglycemia, it is always best to err on the side of caution and treat it as a possible emergency.

Step 2: Check Blood Glucose (If Possible)

If the person is conscious and able to cooperate, checking their blood glucose level with a glucose meter can help confirm hypoglycemia. However, in cases of severe hypoglycemia where the person is unresponsive or seizing, do not attempt to check blood glucose as this could delay immediate treatment.

How to Check Blood Glucose:

Gather Supplies: You will need a glucose meter, test strips, a lancing device, and an alcohol wipe.
Wash Hands: Ensure your hands are clean to prevent infection.
Prepare the Lancing Device: Insert a new lancet into the lancing device.
Clean the Finger: Use an alcohol wipe to clean the side of the person's fingertip.
Prick the Finger: Use the lancing device to prick the cleaned fingertip.
Collect the Blood Sample: Gently squeeze the finger until a small drop of blood appears. Apply the blood to the test strip according to the meter's instructions.
Read the Result: The glucose meter will display the blood glucose level.

Interpreting Blood Glucose Levels:

Below 70 mg/dL (3.9 mmol/L): Indicates hypoglycemia, and immediate treatment is necessary, especially if the person is symptomatic.
Below 54 mg/dL (3.0 mmol/L): Indicates severe hypoglycemia and requires emergency intervention.

If You Cannot Check Blood Glucose:

If a glucose meter is not available or the person is unable to cooperate, do not delay treatment. Proceed with the assumption that the symptoms are due to hypoglycemia and take immediate action.

Table: Interpreting Blood Glucose Levels

| Blood Glucose Level | Interpretation | Action | | :-------------------------- | :----------------------------------------------- | :---------------------------------------------------------------------------------------------------------- | | Below 70 mg/dL (3.9 mmol/L) | Hypoglycemia | If conscious, give fast-acting carbohydrates. If unconscious, proceed with glucagon or call emergency services. | | Below 54 mg/dL (3.0 mmol/L) | Severe Hypoglycemia | Administer glucagon or call emergency services immediately. | | Above 70 mg/dL (3.9 mmol/L) | Unlikely to be hypoglycemia, assess other causes | Monitor symptoms and consider other possible medical conditions. |

Important: Always prioritize safety and prompt action over obtaining a blood glucose reading if the person is in severe distress or unable to cooperate.

Step 3: Administer Glucagon (If Available)

Glucagon is a hormone that stimulates the liver to release stored glucose into the bloodstream. It is a crucial medication for treating severe hypoglycemia in people who are unable to take oral glucose. Glucagon is typically administered by injection, and it's essential to know how to use it correctly.

Types of Glucagon Kits:

There are several types of glucagon kits available, including:

Traditional Glucagon Emergency Kit: This kit contains a vial of powdered glucagon and a syringe filled with sterile diluent. The diluent must be injected into the vial, mixed, and then drawn back into the syringe for injection.
Nasal Glucagon (Baqsimi): This is a needle-free option that comes as a pre-filled nasal spray. It is administered by spraying into one nostril.
Premixed Glucagon Pen (Gvoke HypoPen): This is an auto-injector pen that delivers a pre-measured dose of glucagon with a simple push of a button.

How to Administer Glucagon Injection:

Traditional Glucagon Emergency Kit:

Prepare the Injection: Remove the caps from the vial of glucagon powder and the syringe of sterile diluent.
Mix the Solution: Inject the entire contents of the syringe into the vial of glucagon powder. Gently roll the vial between your hands (do not shake) until the glucagon is completely dissolved. The solution should be clear.
Draw Up the Dose: Draw the reconstituted glucagon solution back into the syringe.
Choose an Injection Site: The injection can be given in the upper arm, thigh, or buttock.
Clean the Injection Site: Clean the skin with an alcohol wipe.
Inject the Glucagon: Pinch the skin at the injection site and insert the needle at a 90-degree angle. Push the plunger to inject the glucagon.
Remove the Needle: Remove the needle and apply gentle pressure to the injection site with a clean cotton ball.
Turn the person onto their side: As the person regains conciousness they may vomit. Turning them onto their side will prevent them from choking.

Important Notes:

Dosage: The standard dose of glucagon is 1 mg for adults and children who weigh more than 44 pounds (20 kg). For children who weigh less than 44 pounds, the dose is 0.5 mg.
Storage: Check the expiration date on the glucagon kit and store it at room temperature, away from direct sunlight and extreme temperatures.

How to Administer Nasal Glucagon (Baqsimi):

Remove the Device: Open the package and remove the nasal glucagon device.
Administer the Dose: Hold the device between your fingers and thumb. Insert the tip of the device into one nostril and press the plunger firmly to release the glucagon powder. It is not necessary to inhale.
Discard the Device: Dispose of the used device properly.

How to Administer Premixed Glucagon Pen (Gvoke HypoPen):

Remove the Cap: Remove the cap from the pen.
Choose an Injection Site: Select an injection site on the outer thigh or lower abdomen.
Administer the Injection: Press the pen firmly against the skin at a 90-degree angle and hold it in place until the injection is complete (usually about 5 seconds).
Remove the Pen: Remove the pen and dispose of it properly.

What to Expect After Glucagon Administration:

Response Time: It may take 10-15 minutes for the person to regain consciousness after glucagon administration.
Possible Side Effects: Common side effects include nausea, vomiting, and headache.
Post-Treatment Care: Once the person is awake and able to swallow, give them a long-acting source of carbohydrates, such as a sandwich or crackers with peanut butter, to stabilize their blood sugar.

Important: Even if the person responds to glucagon, it is still essential to seek immediate medical attention to determine the cause of the hypoglycemia and prevent future episodes.

Step 4: Call for Emergency Medical Assistance

Regardless of whether glucagon is available or effective, it is crucial to call for emergency medical assistance immediately. Hypoglycemia can have serious consequences, and professional medical evaluation is necessary.

When to Call Emergency Services:

Unconsciousness: The person is unresponsive and cannot be awakened.
Seizures: The person is experiencing uncontrolled muscle contractions.
Glucagon Not Available: You do not have glucagon on hand.
No Improvement After Glucagon: The person does not regain consciousness within 15 minutes of glucagon administration.
Breathing Difficulties: The person is having trouble breathing.
Uncertainty: You are unsure about the situation or how to proceed.

What to Tell the Emergency Dispatcher:

When you call for emergency assistance, provide the following information:

Your Location: Provide the exact address and any landmarks to help the emergency responders find you quickly.
The Situation: Explain that the person is experiencing severe hypoglycemia and is unconscious or having seizures.
Medical History: If known, mention that the person has diabetes and any other relevant medical conditions.
Treatment Given: Inform the dispatcher if you have administered glucagon and the time it was given.
Person's Condition: Describe the person's current condition, including their level of consciousness, breathing, and any other symptoms.

While Waiting for Emergency Services:

Stay Calm: Try to remain calm and reassure the person if they are conscious.
Monitor Breathing: Check the person's breathing and be prepared to provide rescue breathing or CPR if necessary.
Turn the Person on Their Side: If the person is unconscious but breathing, place them in the recovery position (on their side) to prevent choking if they vomit.
Gather Medical Information: Collect any relevant medical information, such as a list of medications, allergies, and emergency contact information, to give to the paramedics.

Important:

Do not give the person anything to eat or drink if they are unconscious or having seizures, as this could cause choking.
Do not attempt to move the person unless they are in immediate danger, as this could cause further injury.
Follow the instructions of the emergency dispatcher and provide any additional information they request.

Step 5: Provide Follow-Up Care and Prevention

After the immediate emergency has been addressed, it is essential to provide follow-up care and take steps to prevent future episodes of severe hypoglycemia.

Medical Evaluation:

Hospital Visit: After a severe hypoglycemic event, a visit to the hospital or a medical facility is crucial. Healthcare professionals can conduct thorough evaluations to determine the underlying cause of the episode.
Diabetes Management Review: Healthcare providers will review the person's diabetes management plan, which may include adjustments to medication dosages, meal planning, and exercise routines.
Underlying Conditions: Doctors may investigate any underlying medical conditions that could contribute to hypoglycemia, such as kidney or liver problems.

Adjusting Diabetes Management:

Medication Review: The healthcare team will carefully assess the person's medication regimen. Changes might be made to the type, dosage, or timing of insulin or oral diabetes medications to achieve better blood sugar control.
Meal Planning: A registered dietitian can assist in developing a meal plan that helps stabilize blood sugar levels. This plan will emphasize regular meals, consistent carbohydrate intake, and avoidance of skipped meals.
Exercise Adjustments: If exercise is a contributing factor, adjustments may be needed. This can involve monitoring blood sugar levels before, during, and after physical activity and making changes to insulin dosages or carbohydrate intake accordingly.

Educating Caregivers and Family Members:

Hypoglycemia Recognition: Educate caregivers and family members about the signs and symptoms of hypoglycemia, so they can quickly recognize and respond to future episodes.
Glucagon Administration: Provide training on how to administer glucagon, including the correct dosage and injection technique. Ensure that glucagon kits are readily available and not expired.
Emergency Protocols: Establish clear emergency protocols that outline steps to take during a severe hypoglycemic event. Include contact information for emergency services, healthcare providers, and emergency contacts.
Continuous Glucose Monitoring (CGM): Continuous glucose monitoring (CGM) systems have been shown to effectively prevent hypoglycemia in many trials, which enable users to intervene if blood sugar starts to drop. CGMs sound an alarm when blood sugar drops to a dangerous level or drops at a dangerous rate. They allow the user to take action before an emergency situation occurs.
Automated insulin delivery systems: also known as artificial pancreas, automatically adjust insulin doses, offering even greater protection against hypoglycemia.

Preventing Future Episodes:

Regular Blood Sugar Monitoring: Encourage frequent blood sugar monitoring to identify trends and make timely adjustments to medication and lifestyle.
Wearing a Medical Alert: Advise the person with diabetes to wear a medical alert bracelet or necklace that indicates their condition. This can provide vital information to emergency responders if they are found unconscious.
Carrying Fast-Acting Carbohydrates: Encourage the person to carry fast-acting carbohydrates, such as glucose tablets or juice, to treat mild hypoglycemia promptly.
Maintaining Regular Check-Ups: Emphasize the importance of regular check-ups with the healthcare team to monitor diabetes control and make necessary adjustments.

By providing thorough follow-up care and implementing preventive strategies, you can help minimize the risk of future severe hypoglycemic events and improve the quality of life for the person with diabetes.