Diabetes is a chronic condition in which the body struggles to produce or respond to insulin, the hormone which regulates blood sugar levels. A diabetic emergency happens when a person’s blood glucose level goes outside the normal range, resulting in either too much sugar in the blood (hyperglycaemia) or too little sugar in the blood (hypoglycaemia). 442 million adults have diabetes worldwide, or one in 11 people. The number of diabetes cases worldwide has quadrupled since 1990 (WHO, 2020). A high blood sugar level (hyperglycaemia) may evolve gradually and can be asymptomatic over several hours or even days. A low blood sugar level (hypoglycaemia) is usually sudden and life-threatening and therefore forms the focus of this topic.
Guidelines
- Oral glucose administration (swallowing or eating glucose) should be used for an adult or child with suspected hypoglycaemia who is responsive and able to swallow.**
> First aid providers should give glucose tablets to a person who has symptoms of hypoglycaemia and is responsive.** - If oral glucose (e.g. tablets or dietary sugars) is not available, a glucose gel can be given to an adult or child with suspected hypoglycaemia who is responsive and able to swallow. These gels are both absorbed into the cheeks (buccal) and swallowed (oral). *
- Sublingual glucose administration (putting glucose under the tongue) may be used for suspected hypoglycaemia in children who may be uncooperative with swallowing a glucose substance. *
> If glucose tablets are not available, various forms of dietary sugars such as Skittles, Mentos, sugar cubes, jellybeans or orange juice can be used to treat the symptoms of hypoglycaemia in a responsive person. *
Good practice points
- 15g to 20g of glucose tablets should be used to treat symptomatic hypoglycaemia in responsive babies, children and adults.
- Glucose administration should be repeated if symptoms continue after 15 minutes.
- If it is unclear if the person is hypoglycaemic or hyperglycaemic, the first aid provider should provide care for hypoglycaemia.
Chain of survival behaviours
Prevent and prepare
- People who are diabetic should be encouraged to carry blood testing kits with them as well as insulin or other oral medication or sugary food.
- People who are diabetic should be advised to alert their family and friends to their condition and inform them on how to respond in an emergency.
Early recognition
Talk to the person. They may be able to tell you they are having a diabetic emergency and how you can help them.
Someone with low blood sugar may experience:
- sweating with cold, clammy skin
- weakness, faintness or hunger
- drowsiness, restlessness, aggressiveness (often resembling drunkenness)
- headache
- rapid pulse
- muscle tremors
- deteriorating level of response and leading eventually to seizures or unresponsiveness.
First aid steps
- Help the person to sit down.
- If the person has their own glucose or another sugar source, help them to take 15-20 grams of it. If they do not, give them a sugary (non-diet) drink, such as fruit juice, or some sugar (such as three teaspoons of sugar or three pieces of candy, like jellybeans).
- If symptoms continue after 15 minutes, give the person a repeated amount of glucose or sugar substance.
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CAUTION
Only give the person something to eat or drink if they are responsive and able to swallow.
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Access help
- If the person’s condition does not improve quickly (around 30 minutes) or they become unresponsive access EMS. Monitor the person’s level of responsiveness, breathing and circulation while waiting for help to arrive.
Advise the person to seek medical help if their symptoms are occurring more frequently than usual or if they have a fever.
Recovery
- If the person starts to feel better, advise them they can eat some slow-acting sugars (e.g., a slice of bread or a waffle).
- Encourage them or their companion to measure their blood sugar level.
Education considerations
Learner considerations
- Learners may have some misunderstandings, or pre-existing notions, of those impacted by diabetes (such as only overweight people get diabetes, it only affects middle-aged men, or it is a rich person’s disease). Ensure learners know diabetes (and therefore diabetic emergencies) could affect anyone.
- Introducing the terms hyperglycaemia and hypoglycaemia may be important for some learners; however, you may consider keeping language to “high blood sugar” or “low blood sugar”, particularly for children.
Facilitation tips and tools
- Explore different ways in which learners can help the people they live or work with, who may have diabetes, recognise the signs of a diabetic emergency.
- Even in an emergency, the ill person might be able to tell you what to do, so encourage learners to listen to them and act accordingly.
- Emphasise the importance of recognising low blood sugar as it requires immediate care. If the brain is deprived of sugar, this can lead to Seizures and possible brain damage.
- Emphasise that giving sugar to someone who has high blood sugar is unlikely to harm them. Whereas, not giving someone sugar who urgently needs it can be much more harmful.
- Emphasise that diet food and drinks do not contain any sugar and will not raise the sugar levels of someone having a diabetic emergency.
- Encourage learners to share their experiences with diabetic emergencies. For example, if they have a family member who has experienced a diabetic emergency. Sharing experiences can help people gain confidence and act effectively if the same thing happens again.
Learning connections
- If the person becomes unresponsive, open their airway and check for breathing. See Unresponsiveness.
- If the person has a Seizure, protect them from injury.
- Diabetes can damage blood vessels and cause other serious conditions such as a heart attack (see Chest pain) or Stroke.
Scientific foundation
Systematic reviews
The International Liaison Committee on Resuscitation (ILCOR) conducted two systematic reviews on hypoglycaemia.
Dietary sugars versus glucose tablets
The first systematic review looked at which dietary forms of sugar, compared to a standard dose (15g to 20g) of glucose tablets, should be used when providing first aid to someone experiencing hypoglycaemia (Carlson et al., 2017). The four studies identified all compared glucose tablets with sucrose, fructose, orange juice, jellybeans, Mentos and milk.
For the important outcome of clinical relief from hypoglycaemia in 15 minutes or less, three randomised controlled trials were included. Pooled data from 502 people with diabetes treated with dietary sugars (sucrose, fructose, orange juice, jellybeans, Mentos, and milk) and 223 people treated with glucose tablets (15–20 g) showed a benefit with glucose tablets. There was a slower resolution of symptoms 15 minutes after a person with diabetes was treated with dietary sugars compared with glucose tablets. Low-certainty evidence downgraded for risk of bias and imprecision.
For the important outcome of blood glucose (at least a 20-mg/dL increase of blood glucose by 20 minutes), one observational study is included. In it, 13 people with diabetes were treated with dietary sugars and nine were treated with glucose tablets. It showed a benefit with glucose tablets. Fewer people demonstrated a 20-mg/dL increase in blood glucose level 20 minutes after treatment when treated with dietary sugars compared with glucose tablets. Very low-certainty evidence downgraded for risk of bias and imprecision.
For the critical outcome of time to resolution of symptoms, the important outcome of risk of complications (e.g., aspiration), and the low-priority outcome of hospital length of stay, there were no human trials found.
First aid glucose administration routes
In the second systematic review, De Buck et al. (2019) identified the following four studies:
- One randomised study that compared sublingual glucose administration in the form of table sugar, with oral administration of 42 hypoglycaemic children between the ages of one and 15
- Two non-randomised studies that compared buccal glucose administration with oral administration in 23 healthy, fasting, adult volunteers
- One randomised study that compared a dextrose gel with oral administration of glucose in 18 people with type one diabetes and hypoglycaemia.
Providing sugar under the tongue (sublingual) resulted in a more significant rise in blood glucose after 20 minutes than giving the sugar orally. However, this was in a specific setting and included children with hypoglycaemia and symptoms of malaria or respiratory tract infection. On the other hand, giving glucose by inside cheek absorption (buccal) route resulted in a lower blood glucose concentration than giving it orally. For dextrose gel (where glucose is given through a combination of oral swallowing and via cheek absorption), results showed no clear benefit compared to oral glucose administration (taking glucose tablets or glucose solutions). Most studies did not report on time to resolution of symptoms, resolution of hypoglycaemia as defined by blood glucose levels above a certain threshold, time to resolution of hypoglycaemia, adverse events or treatment delay.
The evidence is of very low certainty due to limitations in study design, few studies and the small number of participants in the studies, and because half of the studies were performed with healthy volunteers rather than in people with characteristic hypoglycaemia.
References
Systematic reviews
Carlson JN, Schunder-Tatzber S, Neilson CJ, Hood N. (2017). Dietary sugars versus glucose tablets for first-aid treatment of symptomatic hypoglycaemia in awake patients with diabetes: a systematic review and meta-analysis. Emergency Medicine Journal. Feb;34(2):100-106. Retrieved from https://pubmed.ncbi.nlm.nih.gov/27644757/
De Buck E, Borra V, Carlson JN, Zideman DA, Singletary EM, Djärv T. (2019) First aid glucose administration routes for symptomatic hypoglycaemia. Cochrane Database Systematic Reviews Rev. Apr 11;4(4): CD013283. Retrieved from https://pubmed.ncbi.nlm.nih.gov/30973639/
Singletary, E. M., Zideman, D. A., Bendall, J. C., Berry, D. C., Borra, V., Carlson, J. N., … & Douma, M. J. (2020). 2020 International Consensus on First Aid Science with Treatment Recommendations. Circulation, 142(16_suppl_1), S284-S334. DOI 10.1161/CIR.0000000000000897
Singletary, E.M., Zideman, D.A., Bendall, J.C., Berry, D.C., Borra, V., Carlson, J.N., Cassan, P., …&, Lee, C.C., (2020). International Consensus on First Aid Science with Treatment Recommendations. Resuscitation. 2020 Nov;156:A240-A282. DOI 10.1016/j.resuscitation.2020.09.016
Non-systematic reviews
World Health Organisation, (2010). Diabetes. Diabetes Facts and Figures – Infographics. Retrieved from https://www.who.int/diabetes/infographic/fr/
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