Severe Hypoglycemia: A Step-by-Step Emergency Guide Severe hypoglycemia, or critically low blood sugar, is a dangerous condition that can occur in peo...

Severe Hypoglycemia: A Step-by-Step Emergency Guide

Severe hypoglycemia, or critically low blood sugar, is a dangerous condition that can occur in people with diabetes, especially those taking insulin or certain oral medications. It's crucial to understand what it is, how to recognize it, and how to act quickly to prevent serious complications like seizures, loss of consciousness, or even death. This guide provides a step-by-step approach to handling a severe hypoglycemic event.

Understanding Severe Hypoglycemia

Hypoglycemia occurs when blood glucose levels drop too low – usually below 70 mg/dL (3.9 mmol/L). Severe hypoglycemia is defined as an episode where the individual requires assistance from another person to actively administer carbohydrates, glucagon, or take other corrective actions.

Causes of Severe Hypoglycemia

Several factors can contribute to severe hypoglycemia:

Excess Insulin: Taking too much insulin or injecting it at the wrong time.
Missed or Delayed Meals: Not eating enough carbohydrates or skipping meals.
Increased Physical Activity: Exercising more intensely or for longer durations than usual without adjusting medication or food intake.
Alcohol Consumption: Alcohol can interfere with the liver's ability to release glucose.
Certain Medications: Some oral diabetes medications, particularly sulfonylureas, can increase the risk of hypoglycemia.
Kidney or Liver Problems: These conditions can affect how the body processes insulin and glucose.
Illness: Being sick can affect appetite and insulin requirements.
Incorrect Insulin Dosage: Errors in insulin measurement.

Recognizing the Signs and Symptoms

Being able to quickly recognize the signs of hypoglycemia is critical. The symptoms can vary from person to person and may include:

Shakiness
Sweating
Dizziness or Lightheadedness
Confusion or Difficulty Concentrating
Rapid Heartbeat
Blurred Vision
Headache
Weakness
Slurred Speech
Irritability or Anxiety
Loss of Coordination
Seizures
Loss of Consciousness

It's crucial to differentiate between mild, moderate, and severe symptoms. In mild cases, the person can usually treat themselves. Severe hypoglycemia is characterized by symptoms that prevent the individual from treating themselves effectively and requires outside assistance.

Step-by-Step Emergency Response

When severe hypoglycemia occurs, prompt action is essential. Here's a step-by-step guide to help you respond effectively:

Step 1: Assess the Situation

Is the person conscious? Determine their level of consciousness. Are they able to swallow and follow simple instructions?
Are they able to self-treat? If the person is alert enough to eat or drink on their own, encourage them to do so.
Do you suspect severe hypoglycemia? If the person is showing signs of confusion, disorientation, or is unable to follow instructions, assume it is severe hypoglycemia.

Step 2: If the Person is Conscious and Able to Swallow

Administer Fast-Acting Carbohydrates: Give them a quick source of sugar. Options include:
- Glucose Tablets or Gel: Follow the package instructions. Typically, 15-20 grams of glucose is recommended.
- Fruit Juice: 4 ounces (120 ml) of fruit juice (orange, apple, or grape).
- Regular Soda (non-diet): 4 ounces (120 ml) of regular soda.
- Hard Candies: 3-4 hard candies (ensure they can be safely chewed and swallowed).
- Honey or Sugar: 1 tablespoon.
Avoid Fatty Foods: Foods high in fat can slow down the absorption of glucose. Avoid giving them chocolate, cookies, or ice cream initially.
Recheck Blood Sugar: After 15 minutes, recheck their blood sugar level if possible using a glucose meter. If it's still below 70 mg/dL (3.9 mmol/L), repeat the carbohydrate administration.
Follow Up with a Longer-Acting Carbohydrate: Once their blood sugar is above 70 mg/dL, provide a longer-acting carbohydrate source, such as a sandwich with protein or a piece of fruit with crackers and peanut butter, to prevent another drop.

Step 3: If the Person is Unconscious or Unable to Swallow

This is a medical emergency!

Do NOT attempt to give them anything by mouth: This could cause choking.
Administer Glucagon: Glucagon is a hormone that raises blood sugar levels. If a glucagon emergency kit is available and you know how to use it, administer it immediately.
- Locate the Glucagon Kit: It usually contains a syringe with sterile water and a vial of powdered glucagon.
- Prepare the Injection: Follow the instructions provided with the kit to mix the glucagon solution.
- Administer the Injection: Inject the glucagon into the person's thigh, arm, or buttock. The injection site does not need to be cleaned with alcohol beforehand.
Call Emergency Services (911 in the US or your local emergency number): Even if the person regains consciousness after glucagon administration, it is vital to seek immediate medical attention. Glucagon's effect is temporary, and they may need further treatment. Explain the situation clearly, stating that the person is experiencing severe hypoglycemia and has received glucagon.
Position the Person on Their Side: To prevent choking in case of vomiting.
Stay with the Person: Monitor their breathing and level of consciousness until emergency services arrive.
Inform Emergency Responders: Tell them the person has diabetes and received a glucagon injection. Provide any relevant medical information, such as medications they are taking.

Step 4: After the Emergency

Follow Up with a Healthcare Provider: Even if the person recovers fully, a visit to their doctor is crucial to determine the cause of the severe hypoglycemic episode and adjust their diabetes management plan accordingly.
Review the Incident: Analyze what might have triggered the event. Were there any changes in medication, diet, or activity levels?
Educate Yourself and Others: Ensure that the person with diabetes and their close contacts (family, friends, coworkers) are well-educated about hypoglycemia, its symptoms, and emergency procedures.
Consider a Medical ID: A medical ID bracelet or necklace can alert first responders to the person's diabetes in case of an emergency.

Glucagon: A Lifesaving Tool

Glucagon is a synthetic hormone that is crucial in treating severe hypoglycemia. It works by stimulating the liver to release stored glucose into the bloodstream, raising blood sugar levels. It's essential for people with diabetes, particularly those at risk for severe hypoglycemia, to have a glucagon emergency kit readily available.

Types of Glucagon

Glucagon kits come in various forms, including:

Traditional Glucagon Kit: Requires mixing the powdered glucagon with a liquid before injection. This is the older, more traditional type.
Nasal Glucagon (Baqsimi): A needle-free option that is administered as a nasal spray. It's pre-mixed and ready to use.
Pre-filled Syringe (Gvoke HypoPen): An auto-injector that delivers a pre-measured dose of glucagon with the push of a button.

Key Considerations for Glucagon

Prescription Required: Glucagon requires a prescription from a healthcare provider.
Training: It's important to receive proper training on how to use the specific type of glucagon kit prescribed. Healthcare providers, diabetes educators, and pharmacists can provide instruction.
Expiration Date: Check the expiration date of the glucagon kit regularly and replace it before it expires.
Storage: Store the glucagon kit in a cool, dry place, away from direct sunlight and extreme temperatures.
Inform Others: Make sure family members, friends, and caregivers know where the glucagon kit is stored and how to use it.

Preventing Severe Hypoglycemia

Prevention is always better than cure. Here are some tips to help prevent severe hypoglycemic episodes:

Regular Blood Glucose Monitoring: Check blood sugar levels regularly, especially before meals, before bedtime, and before, during, and after exercise.
Adhere to a Consistent Meal Schedule: Eat meals and snacks at regular intervals to maintain stable blood sugar levels. Don't skip meals.
Balance Insulin Dosage with Carbohydrate Intake and Activity: Work closely with a healthcare provider to adjust insulin dosages based on food intake, activity levels, and blood sugar readings.
Learn to Recognize Early Signs of Hypoglycemia: Treat mild hypoglycemia promptly to prevent it from progressing to a severe episode.
Carry a Source of Fast-Acting Carbohydrates: Always have glucose tablets, gel, or other quick-acting carbohydrates on hand in case of low blood sugar.
Educate Family and Friends: Make sure those around you know how to recognize hypoglycemia and how to administer glucagon in an emergency.
Medical Alert Identification: Wear a medical ID bracelet or necklace that identifies you as having diabetes.
Review Medications Regularly: Discuss all medications, including non-diabetes medications, with your healthcare provider to identify any that may increase the risk of hypoglycemia.
Consider a Continuous Glucose Monitor (CGM): CGMs can provide real-time blood sugar readings and alert you to trends and potential lows, allowing for proactive management. Some CGMs can even alert designated contacts if your blood sugar drops to dangerous levels.
Insulin Pump with Low Glucose Suspend Feature: Some insulin pumps have a feature that automatically suspends insulin delivery when blood sugar levels drop to a predefined threshold, helping to prevent hypoglycemia.

Practical Example Scenarios

To illustrate how to respond to severe hypoglycemia, consider these scenarios:

Scenario 1:

Situation: A person with diabetes is found unresponsive at home. Their medical ID bracelet indicates they have diabetes.
Action:
1. Immediately call 911.
2. Locate the glucagon kit (family members know where it is stored).
3. Administer the glucagon injection according to the instructions.
4. Position the person on their side to prevent choking.
5. Wait for emergency services to arrive and provide them with all relevant information.

Scenario 2:

Situation: A person with diabetes is at a restaurant and suddenly becomes confused and disoriented. They are unable to speak clearly or follow instructions.
Action:
1. Recognize the signs of severe hypoglycemia.
2. Ask if anyone present knows how to use glucagon and if they have it with them. If so, have them administer it.
3. If no glucagon is available, call 911.
4. Ensure the person is in a safe position and monitor them until help arrives.

Scenario 3:

Situation: A child with diabetes becomes unresponsive at school.
Action:
1. The school nurse is trained to recognize and treat hypoglycemia.
2. The nurse assesses the child and recognizes severe hypoglycemia.
3. The nurse administers nasal glucagon (Baqsimi) as per protocol.
4. The nurse calls 911 and the child's parents.
5. The nurse stays with the child until emergency services arrive.

Special Considerations

Children: Smaller doses of glucagon may be required for children. Consult with a healthcare provider or pharmacist for specific dosing instructions. Newer glucagon formulations, like nasal glucagon and pre-filled pens, may simplify dosage for children.
Elderly: Older adults may be more susceptible to the effects of hypoglycemia. Monitor them closely and consider potential interactions with other medications. Ensure their caregivers are well-informed about hypoglycemia management.
Beta-Blockers: Some medications, such as beta-blockers, can mask the symptoms of hypoglycemia, making it more difficult to recognize.
Alcohol Consumption: Alcohol can impair the liver's ability to release glucose, increasing the risk of hypoglycemia. Advise people with diabetes to consume alcohol in moderation and always with food.
Recurring Hypoglycemia: If a person experiences frequent or severe hypoglycemia, they may have hypoglycemia unawareness. This means they are no longer able to recognize the early warning signs of low blood sugar. In such cases, working closely with an endocrinologist is crucial to adjust medication and lifestyle factors to improve blood sugar control and restore awareness of hypoglycemia.

Conclusion

Severe hypoglycemia is a serious medical emergency, but with proper knowledge, preparation, and swift action, the risk of serious complications can be significantly reduced. Understanding the causes, recognizing the symptoms, and knowing how to administer glucagon are vital steps in protecting individuals with diabetes. By prioritizing prevention, education, and readily available emergency resources, you can empower yourself and those around you to effectively manage and respond to severe hypoglycemic events. Always consult with a healthcare professional for personalized advice and guidance on diabetes management. Remember, prompt action can save a life.