Emergency Care for Severe Hypoglycemia and Hyperglycemia from Diabetes Medications

When a diabetes medication pushes blood sugar to dangerous lows or sky‑high highs, seconds matter. Whether you’re a caregiver, a person with diabetes, or an EMT, knowing the exact steps can mean the difference between a quick recovery and a life‑threatening event.

Key Takeaways

• Blood glucose below 54 mg/dL requires immediate help; above 250 mg/dL with ketones signals a hyperglycemic crisis.
• Glucagon is the rescue drug for severe hypoglycemia; choose ready‑to‑use forms (Baqsimi nasal powder or Gvoke autoinjector) for speed and safety.
• DKA and HHS demand IV fluids, electrolyte correction, and continuous insulin - never give insulin during a hypoglycemic episode.
• Every insulin‑treated person should carry a glucagon kit, practice administration quarterly, and keep a fast‑acting carbohydrate source on hand.
• Early recognition of ketones and prompt 911 activation are the most effective ways to lower mortality.

What Counts as a Diabetes Medication Emergency?

Two opposite but equally dangerous scenarios can arise from the same drugs:

Severe hypoglycemia is defined by the American Diabetes Association as a blood glucose level below 54 mg/dL (3.0 mmol/L) that requires another person to intervene. Typical triggers are excess insulin, missed meals, or vigorous exercise. Symptoms progress from shakiness and sweating to confusion, seizures, and loss of consciousness.

Severe hyperglycemia includes diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS). DKA shows glucose >250 mg/dL (13.9 mmol/L), blood ketones >1.5 mmol/L, and pH < 7.3. HHS presents with glucose often >600 mg/dL (33.3 mmol/L) and serum osmolality >320 mOsm/kg. Both conditions can lead to coma, cerebral edema, or death if not treated fast.

First Steps: Assess, Call, and Document

1. Measure glucose. If a meter isn’t available, check for obvious signs (cold sweats vs. dry mouth) but don’t assume - always confirm with a test when possible.

2. Call emergency services (911 in the U.S., 000 in Australia) if:

• Glucose < 54 mg/dL and the person is unable to swallow.
• Glucose >250 mg/dL with ketones, fruity breath, or severe dehydration.
• Any loss of consciousness, seizures, or severe vomiting.

3. Record what you know: medication name, last dose, time of last meal, recent exercise, and any illness. This information guides the EMT or ER team.

Rapid Treatment for Severe Hypoglycemia

The goal is to raise blood glucose above 70 mg/dL within minutes.

Glucagon - the main rescue drug

Three formulations are widely available:

For most laypersons, ready‑to‑use forms (Baqsimi or Gvoke) are safest - no reconstitution, clear visual cue, and they work on children as young as 2 years.

Step‑by‑step glucagon administration

1. Check breathing and pulse. If the person is not breathing, start CPR while a bystander prepares glucagon.
2. Remove the glucagon device from its carrier. For nasal powder, tilt the head back slightly and spray both nostrils.
3. For the autoinjector, press firmly against the outer thigh, hold for 5 seconds, then remove.
4. Call 911 if you haven’t already. Stay with the patient.
5. Once glucose rises above 70 mg/dL, give a snack containing carbs and protein (e.g., apple slices with peanut butter) to prevent rebound.

Mild hypoglycemia - the “Rule of 15”

If the person is awake, alert, and can swallow, give exactly 15 g of fast‑acting carbs (4 oz regular soda, 3 glucose tablets, or 1 Tbsp honey). Wait 15 minutes, re‑check glucose, and repeat until >70 mg/dL.

Managing Severe Hyperglycemia: DKA and HHS

Both conditions need immediate hospital care, but the initial steps you can take while waiting for EMS are crucial.

What to do before help arrives

• Encourage the person to sip small amounts of water (if not vomiting) - 250 mL every 15 minutes helps prevent dehydration.
• Do NOT give any insulin unless you are a trained medical professional and have confirmed the condition.
• If a ketone meter is available, log the ketone level; a value ≥1.5 mmol/L signals DKA.

Hospital protocol snapshot

Once the patient reaches the ER, the standard three‑pronged approach kicks in:

1. IV fluids. 0.9 % saline, 1-2 L in the first hour to restore circulation.
2. Electrolyte correction. Add potassium chloride 20-30 mEq/L to the IV bag when serum K⁺ < 5.2 mEq/L; avoid giving insulin until K⁺ is > 3.3 mEq/L.
3. Insulin infusion. A 0.1 unit/kg IV bolus, then 0.1 unit/kg/hr continuous drip. Monitor glucose every hour - target a drop of 50‑100 mg/dL per hour.

For mild DKA (pH > 7.0), some clinicians start with subcutaneous rapid‑acting insulin (lispro 0.3 unit/kg) while fluids are given, but IV insulin remains the gold standard for severe cases.

Choosing the Right Glucagon: Practical Comparison

Cost, insurance coverage, and user comfort often dictate which product a family picks. Below is a quick decision guide.

• Budget‑conscious: Traditional kits are cheapest (~$130) but require preparation skill.
• Speed‑focused: Gvoke autoinjector delivers the drug in <5 seconds - ideal for caregivers with limited training.
• Need for pediatric dosing: Baqsimi is FDA‑approved for children 2 years and up, no needle needed.
• Insurance friendliness: Private plans cover ready‑to‑use products 78 % of the time versus 92 % for kits; check your formulary.

Preventive Strategies and Emergency Kit Essentials

Preparation beats reaction. Build a kit that fits in a purse, backpack, or work locker.

Practice glucagon administration every 3 months using a trainer device. Studies show skill retention drops from 92 % to 45 % after 6 months without rehearsal.

Special Populations: Children, Pregnancy, and Renal Impairment

Kids. Children have faster metabolism, so hypoglycemia can develop in minutes. Use weight‑based glucagon dosing (0.03 mg/kg) when available; otherwise, the standard adult dose works for most kids over 2 years.

Pregnant women. Both hypo‑ and hyperglycemia pose risks to the fetus. Aim for glucose 80‑110 mg/dL. If severe hypoglycemia occurs, glucagon is safe - it does not cross the placenta in harmful amounts.

Renal disease. Reduced kidney function impairs insulin clearance, raising hypoglycemia risk. Glucagon still works, but monitor for fluid overload if using IV fluids during a hyperglycemic crisis.

Common Pitfalls to Avoid

• Giving oral carbs to an unconscious person - risk of aspiration.
• Administering insulin when the patient is actually hypoglycemic - can be fatal.
• Skipping ketone testing in a high‑glucose scenario - you might miss early DKA.
• Relying on expired glucagon - potency drops after the expiration date.
• Assuming “feeling fine” means normal glucose - many severe episodes start with subtle symptoms.

Frequently Asked Questions

Being ready, knowing the exact steps, and having the right tools can turn a terrifying emergency into a manageable situation. Keep your kit stocked, rehearse the process, and act fast - lives depend on it.