How to Treat Diabetic Emergencies

Learn How EMTs & Paramedics Identify, Treat, and Care for Patients with Diabetic Symptoms

Diabetic symptoms (hypoglycemia) are among the top 10 most common emergencies that EMS professionals respond to, accounting for 2.5% of all EMS calls.

(Click here for our list of the most common EMS Emergencies for EMTs and Paramedics).

Diabetes is a group of metabolic disorders that result in high blood sugar levels over a prolonged period of time. Symptoms can include frequent urination, increased thirst, and increased appetite. If left untreated, diabetes can cause many complications. Acute complications can include diabetic ketoacidosis, hyperosmolar hyperglycemic state, or death. Serious long-term complications include cardiovascular disease, stroke, chronic kidney disease, foot ulcers, damage to the nerves, damage to the eyes, and cognitive impairment.

Although diabetes is characterized by high blood sugar, low blood sugar (or hypoglycemia) is one of the main concerns for patients with diabetes. Hypoglycemia occurs when a person’s plasma glucose concentration drops below 70 mg/dL, with most patients not showing symptoms until the plasma glucose levels drop below 55 mg/dL.

Low plasma glucose concentration that requires assistance from another individual qualifies as severe hypoglycemia, and by context, all EMS encounters fall into this category.

As of 2019, an estimated 463 million people had diabetes worldwide (8.8% of the adult population), with type 2 diabetes making up about 90% of the cases. Rates of diabetes are similar in women and men. Trends suggest that rates will continue to rise over time.

Unfortunately, diabetes at least doubles a person’s risk of early death. In 2019, diabetes resulted in approximately 4.2 million deaths and was the 7th leading cause of death worldwide.

Diabetic Symptoms Definition

What is Diabetes?

Diabetes, or more formally “diabetes mellitus,” is a common endocrine disorder that results in high blood sugar levels over prolonged periods. Diabetes is caused by either the pancreas not producing enough insulin or the body’s cells not responding properly to the insulin that’s produced. The primary function of insulin is to regulate the metabolism of carbohydrates, protein, and fat by absorbing glucose sugar from the blood into the liver, fat, and skeletal muscle cells.

There are three main types of diabetes:

Type 1 Diabetes

Type 1 diabetes results from the failure of the pancreas to produce enough insulin due to the loss of beta cells. Type 1 diabetes was previously referred to as insulin-dependent diabetes or juvenile diabetes. An autoimmune response causes the loss of beta cells. However, what causes this autoimmune response remains unknown.

The age group affected by Type 1 is usually children and adolescents, but adults can also develop Type 1 diabetes. Type 1 diabetes must be managed with insulin injections.

Type 2 Diabetes

Type 2 diabetes (also known as non-insulin diabetes or adult-onset diabetes) accounts for approximately 90% of all cases of diabetes.

Type 2 diabetes begins with insulin resistance, a condition in which cells fail to respond to insulin properly. As the disease progresses, a lack of insulin may also develop. The most common cause of Type 2 diabetes is a combination of excessive body weight and insufficient exercise.

Type 2 diabetes may be treated with medications such as insulin sensitizers with or without insulin. Control of blood pressure and maintaining proper foot and eye care are important for people with the disease. Insulin and some oral medications can cause low blood sugar. Weight loss surgery in those with obesity is sometimes an effective measure in those with type 2 diabetes.

Prevention and treatment of type 2 diabetes involve maintaining a healthy diet, regular physical exercise, a normal body weight, and avoiding tobacco use.

Type 2 diabetes most commonly presents itself in people older than 45 years old, but it increasingly occurs in children, adolescents, and younger adults due to rising levels of obesity, physical inactivity, and energy-dense diets.

Gestational Diabetes

The third main form of diabetes is gestational. Although it can occur anytime during pregnancy, gestational diabetes generally affects women during the second and third trimesters of pregnancy. According to the American Diabetes Association, gestational diabetes complicates about 7% of all pregnancies. Women with gestational diabetes, along with their children, have an increased risk of developing type 2 diabetes in the future.

Gestational diabetes occurs when pregnant women without a previous history of diabetes develop high blood sugar levels. Gestational diabetes usually resolves after the birth of the baby.

What is Hypoglycemia?

Hypoglycemia is one of the main concerns for patients with diabetes and the primary reason for a diabetes-related EMS call. Hypoglycemia is a condition in which your blood sugar (glucose) level is lower than normal. Glucose is your body’s primary energy source.

Hypoglycemia occurs when a person’s plasma glucose concentration drops below 70 mg/dL. However, most patients don’t show symptoms until the plasma glucose levels drop below 55 mg/dL.

Low plasma glucose concentration that requires assistance from another individual qualifies as severe hypoglycemia, and by context, all EMS encounters fall into this category.

Hypoglycemia is often related to diabetes treatment. But other drugs and a variety of conditions — many rare — can cause low blood sugar in people who don’t have diabetes.

Hypoglycemia needs immediate treatment when blood sugar levels are low. For many people, a fasting blood sugar of 70 milligrams per deciliter (mg/dL), or 3.9 millimoles per liter (mmol/L), or below should serve as an alert for hypoglycemia.

Treatment involves quickly getting your blood sugar back to normal either with high-sugar foods or drinks or with medications. Long-term treatment requires identifying and treating the cause of hypoglycemia.

Risk Factors for Hypoglycemia

An episode of hypoglycemia, or low blood sugar, can be unpleasant and dangerous. You may also feel confused and have trouble concentrating. Other symptoms of hypoglycemia include dizziness, a fast heart rate, blurry vision, shaking, weakness, and headache.

This is why it’s vital to assess your risk for experiencing hypoglycemia while treating diabetes. Once you know your risk factors, your doctor can help you develop a strategy to prevent hypoglycemia before it becomes serious.

Conditions that may increase your risk of hypoglycemia include:

1. Increased age. The risk of having severe hypoglycemia roughly doubles with each decade of life after age 60. This may because older people are more sensitive to medications.
2. Skipping meals. If you have diabetes, skipping a meal can throw off your blood sugar balance and cause your glucose levels to drop too low. Taking certain diabetes medications without food can significantly increase your chances of having a hypoglycemic episode. Skipping meals can also make you eat more foods high in refined carbohydrates, which aren’t suitable for people with diabetes.
3. Irregular eating patterns. Eating randomly or inconsistently throughout the day can upset the balance between your blood sugar levels and your diabetes medications. Research also shows that people with regular eating habits have a lower risk of hypoglycemia than those with irregular eating habits.
4. Heavy exercise. When you exercise, you use up the glucose in your bloodstream faster and possibly heighten your sensitivity to insulin. To avoid hypoglycemia during exercise, test your blood sugar before, during, and after your workout, then adjust your eating or medication accordingly. You may need to snack or take a glucose tablet before or after exercise to maintain the correct blood sugar levels.
5. Weight loss. Managing your weight is essential to diabetes treatment. But if you lose weight too quickly, it can make you more sensitive to insulin, which could mean you need less insulin. Before you begin a weight loss program, consult with your doctor. You may need to modify your dosage of certain diabetes medications to prevent hypoglycemic episodes.
6. Taking beta-blockers. Beta-blockers can make it challenging to recognize the symptoms of hypoglycemia. For example, one sign of hypoglycemia is a fast heart rate. But beta-blockers can slow your heartbeat so that you won’t recognize this symptom. If you take a beta-blocker, you should check your blood sugar levels more often and eat consistently.
7. Using the same injection site. Insulin that you repeatedly inject into the same spot can cause lipohypertrophy, which is fat and scar tissue that accumulates underneath the surface of your skin. Lipohypertrophy can affect the way your body absorbs insulin, which can put you at a higher risk for both hypoglycemia and hyperglycemia. For this reason, rotating your injection sites is crucial.
8. Antidepressants. The use of antidepressants has been associated with hypoglycemia. Tricyclic antidepressants were more strongly linked with the risk of severe hypoglycemia than selective serotonin reuptake inhibitors. Symptoms of depression, such as loss of appetite, may also contribute to a higher risk of hypoglycemia.
9. Drinking alcohol. Alcohol blocks the production of glucose in the liver. With both alcohol and diabetes medications in your system, your blood sugar can drop quickly. If you drink alcohol, remember to eat a meal or snack before bedtime. Also, be extra careful when monitoring your blood glucose levels the following day.
10. Cognitive dysfunction. People with diabetes who also have cognitive dysfunction, such as dementia or Alzheimer’s disease, may be at higher risk for hypoglycemia. People with cognitive dysfunction may have erratic eating patterns or frequently skip meals. In addition, they may accidentally take the wrong dose of their medication, which can lead to hypoglycemia.
11. Underlying kidney damage. Kidneys play a critical role in metabolizing insulin, reabsorbing glucose, and removing medication from the body. For this reason, people with diabetes and kidney damage can be at a higher risk of hypoglycemia.
12. Underactive thyroid. The thyroid gland releases hormones to help your body regulate and use energy. Hypothyroidism is when the thyroid doesn’t produce enough thyroid hormones, which typically causes your metabolism to slow down. As a result, the diabetes medication lingers in the body, which can lead to hypoglycemia.
13. Gastroparesis. Gastroparesis is a disorder where your stomach empties too slowly. The condition may be the result of disrupted nerve signals in the stomach. While many factors can cause gastroparesis, including viruses or acid reflux, it can also be caused by diabetes. With gastroparesis, your body won’t absorb glucose at a normal rate. If you take insulin with a meal, your blood sugar levels may not respond the way you expect.
14. Having diabetes for a long time. Hypoglycemia risk also increases in people with a more extended history of diabetes. This may be due to taking insulin therapy for a longer period of time.
15. Pregnancy. Pregnancy results in a major change to hormones. Women with diabetes may experience a dip in blood glucose levels during the first 20 weeks of pregnancy. Taking a standard dose of insulin may end up being too much. If you’re pregnant, talk to your doctor about scaling back your insulin dose to avoid hypoglycemia.

Talk to your doctor

If you have any of the above risk factors, talk to your doctor. You should develop a game plan for preventing hypoglycemia.

Depending on your risk, the following guidelines may help prevent hypoglycemia:

• Avoid skipping meals
• Change your insulin injection site frequently
• Ask your doctor how other medications, especially antidepressants or beta-blockers, may affect your risk
• Monitor your blood sugar level when exercising
• If you drink alcohol, eat a snack
• Get tested for hypothyroidism
• When losing weight, ask your doctor if you should adjust the dosage of your diabetes medication

If you experience hypoglycemia, eating a fast-acting carbohydrate, like hard candy or orange juice, will help raise your blood sugar level. You should also see a doctor if you experience mild to moderate hypoglycemic episodes several times a week.

Over time, recurring hypoglycemia can lead to hypoglycemia unawareness. The body and brain no longer produce signs and symptoms that warn of low blood sugar. When this happens, the risk of severe, life-threatening hypoglycemia increases. If you have diabetes, recurring episodes of hypoglycemia, and hypoglycemia unawareness, your doctor might modify your treatment to raise your blood sugar level goals and recommend blood glucose awareness training.

Signs and Symptoms of Hypoglycemia

Signs and symptoms of low blood sugar can include:

• An irregular or fast heartbeat
• Fatigue
• Pale skin
• Shakiness
• Anxiety
• Sweating
• Hunger
• Irritability
• Tingling or numbness of the lips, tongue, or cheek

As hypoglycemia worsens, signs and symptoms can include:

• Confusion, abnormal behavior, or both, such as the inability to complete routine tasks
• Visual disturbances, such as blurred vision
• Seizures
• Loss of consciousness

When to Call 911 for Hypoglycemia

Seek a doctor’s help immediately if:

• You have what might be hypoglycemia symptoms, and you don’t have diabetes.
• You have diabetes, and hypoglycemia isn’t responding to treatment, such as drinking juice or regular soft drinks, eating candy, or taking glucose tablets.

Call 911 for someone with diabetes or a history of hypoglycemia who has symptoms of severe hypoglycemia or loses consciousness.

How to Treat Diabetic Symptoms (Hypoglycemia)

If you use insulin or another diabetes medication to lower your blood sugar and have signs and symptoms of hypoglycemia, test your blood sugar levels with a blood glucose meter. If the result shows low blood sugar (under 70 mg/dL), treat accordingly.

If you don’t use medication known to cause hypoglycemia, your doctor will want to know the following:

• What were your signs and symptoms? If you don’t have signs and symptoms of hypoglycemia during your initial visit with your doctor, he or she might have you fast overnight or longer. This will allow low blood sugar symptoms to occur so that he or she can make a diagnosis.

It’s also possible that you’ll need to undergo an extended fast in a hospital setting. If your symptoms occur after a meal, your doctor will want to test your glucose levels after you eat.

• What is your blood sugar level when you’re having symptoms? Your doctor will draw a sample of your blood to be analyzed in the laboratory.
• Do your symptoms disappear when blood sugar levels increase?

Also, your doctor will likely conduct a physical examination and review your medical history.

Immediate treatment of hypoglycemia

If you have symptoms of hypoglycemia, do the following:

• Eat or drink 15 to 20 grams of fast-acting carbohydrates. These are sugary foods without protein or fat that are easily converted to sugar in the body. Try glucose tablets or gel, fruit juice, regular – not diet – soft drinks, honey, and sugary candy.
• Recheck blood sugar levels 15 minutes after treatment. If blood sugar levels are still under 70 mg/dL (3.9 mmol/L), eat or drink another 15 to 20 grams of fast-acting carbohydrate, and recheck the blood sugar level in 15 minutes. Repeat these steps until the blood sugar is above 70 mg/dL (3.9 mmol/L).
• Have a snack or meal. Once your blood sugar is normal, eating a snack or meal can help stabilize it and replenish your body’s glycogen stores.

Immediate treatment of severe hypoglycemia

Hypoglycemia is considered severe if you need help from someone to recover. For example, if you can’t eat, you might need a glucagon injection or intravenous glucose.

In general, people with diabetes who are treated with insulin should have a glucagon kit for emergencies. Family and friends need to know where to find the kit and how to use it in case of emergency.

If you’re helping someone who is unconscious, don’t try to give the person food or drink. If there’s no glucagon kit available or you don’t know how to use it, call for emergency medical help immediately.

Treatment of an underlying condition

Preventing recurrent hypoglycemia requires your doctor to identify the underlying condition and treat it. Depending on the underlying cause, treatment may involve:

• Medications. If a medication is the cause of your hypoglycemia, your doctor will likely suggest changing or stopping the medication or adjusting the dosage.
• Tumor treatment. A tumor in your pancreas is treated by surgical removal of the tumor. In some cases, partial removal of the pancreas is necessary.

How Do EMTs & Paramedics Treat Diabetic Symptoms?

In the event of a diabetic symptoms emergency, an EMT or paramedic will likely be the first healthcare provider to assess and treat your condition.

EMTs have a clear set of protocols and procedures for most of the 911 emergencies they encounter, including diabetic symptoms. For all suspected diabetic symptoms, the first step is a rapid and systematic assessment of the patient. For this assessment, most EMS providers will use the ABCDE approach.

ABCDE stands for Airway, Breathing, Circulation, Disability, and Exposure. The ABCDE approach is applicable in all clinical emergencies for immediate assessment and treatment. It can be used in the street with or without any equipment. It can also be used in a more advanced form where emergency medical services are available, including emergency rooms, hospitals, or intensive care units.

Treatment Guidelines & Resources for Medical First Responders

The National Model EMS Clinical Guidelines by the National Association of State EMT Officials (NASEMSO) provides treatment guidelines for hyperglycemia on page 75 and hypoglycemia on page 78. NASEMSO maintains these guidelines to facilitate state and local EMS system clinical guidelines, protocols, and operating procedures. These guidelines are either evidence-based or consensus-based and have been formatted for use by EMS professionals.

The guidelines include the following inclusion criteria for hyperglycemia:

1. Adult or pediatric patient with altered level of consciousness [see Altered Mental Status guideline]
2. Adult or pediatric patient with stroke symptoms (e.g., hemiparesis, dysarthria) [see Suspected Stroke/Transient Ischemic Attack guideline]
3. Adult or pediatric patient with seizure [see Seizures guideline]
4. Adult or pediatric patient with symptoms of hyperglycemia (e.g., polyuria, polydipsia, weakness, dizziness, abdominal pain, tachypnea)
5. Adult or pediatric patient with a history of diabetes and other medical symptoms

Exclusion Criteria:  Patient in cardiac arrest

The guidelines include the following inclusion criteria for hypoglycemia:

1. Adult or pediatric patient with blood glucose less than 60 mg/dL with symptoms of hypoglycemia
2. Adult or pediatric patient with altered level of consciousness [see Altered Mental Status guideline]
3. Adult or pediatric patient with stroke symptoms (e.g., hemiparesis, dysarthria) [see Suspected Stroke/Transient Ischemic Attack guideline]
4. Adult or pediatric patient with seizure [see Seizures guideline]
5. Adult or pediatric patient with a history of diabetes and other medical symptoms
6. Pediatric patient with suspected alcohol ingestion
7. Adult patient who appears to be intoxicated

Exclusion Criteria:  Patient in cardiac arrest

EMS Protocol for Diabetic Emergencies

This protocol may be used to treat patients who have been previously diagnosed with diabetes and are currently experiencing an altered mental status:

1. Perform initial patient assessment. Look for medical alert tags.
2. Perform focused history and physical exam
   • Determine last meal, last medication dose (including insulin type(s), number of units, time of administration, and oral hypoglycemic medications) B. Any related illness
3. Administer oxygen.
4. Perform blood sugar reading using a glucometer.
   • If blood sugar is less than 60 mg/dl and if:
     • Patient is awake enough to protect own airway. Administer oral sugar/glucose by mouth.
     • Patient is semi-conscious but still has a gag reflex. Place a small amount of oral glucose between the patient’s cheek and gum.
     • Patient has an altered level of consciousness. Follow protocol for Altered Level of Consciousness.
     • EMT INTERMEDIATE TECHNICIAN – If blood glucose is less than 60, be prepared to start I.V. D5W, and run in 200 cc D5W or administer Glucagon I.M. 1mg. for adult, 0.5 mg for child less than 1 year or administer 50% Dextrose through the I.V. CONTACT MEDICAL CONTROL to report results. Recheck blood glucose in 10 to 15 minutes.
     • If blood glucose is 60 or more, start I.V. NS. If systolic BP under 90, run in 200 cc NS, recheck BP, then titrate I.V. rate to patient’s condition (see discussion of “Rates of I.V. fluids” in the Intravenous Lines protocol).
5. CONTACT MEDICAL CONTROL. Obtain order to administer Glucagon.
   • Adult/Child – Glucagon 1 mg. I.M.
   • Child less than 1 year-Glucagon 0.5 mg I.M. in anterolateral thigh.
6. Repeat testing of blood sugar in 15-20 minutes. REPORT TO MEDICAL CONTROL. Glucagon may be repeated in 20 minutes with physician authorization.
7. Transport. Consider ALS intercept for hypoglycemic patients unresponsive to initial treatment.

Treat and Release Protocol (Medical Control Authorization ONLY)

Consider no transport with medical control authorization of patients who have received the treatment noted above and have met ALL the following criteria:

•  Blood Sugar greater than 70 mg/dl
•  Patient is able to eat a meal
• Patient is in the company of responsible adult(s) who will stay with him/her for at least 12 hours or ensure that somebody else does
• Patient agrees to contact their primary health care provider within 24 hours
•  Patient has the capability of measuring their own blood sugar and adjusting their medications (i.e., insulin) accordingly
• There are no other acute medical issues involved (i.e., suspected stroke, MI, trauma, drugs, alcohol, use of oral hypoglycemic medications, or serious infections.

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