Diabetic Emergencies: Hypoglycemia and Hyperglycemia

By Jointra Editorial Team, Certified EMT

Diabetes in the Emergency Setting

Diabetes affects over 37 million Americans, and EMS providers encounter diabetic emergencies regularly. The two major acute complications — hypoglycemia and hyperglycemia — can both present as altered mental status, making differentiation critical. The treatments are opposite, so getting it wrong matters.

Hypoglycemia (Low Blood Sugar)

Defined as blood glucose below 70 mg/dL. Symptoms typically appear below 60 mg/dL and become severe below 50 mg/dL.

Why It Happens

• Too much insulin or oral hypoglycemic medication
• Missed or delayed meal
• Unusual physical activity
• Alcohol use

Signs and Symptoms

Early (adrenergic — the body releasing epinephrine):

• Shakiness, trembling
• Diaphoresis (sweating)
• Tachycardia, palpitations
• Anxiety, irritability
• Hunger

Late (neuroglycopenic — the brain starving):

• Confusion, difficulty concentrating
• Combativeness or unusual behavior (often mistaken for intoxication)
• Seizure
• Unconsciousness

Treatment

Conscious, able to swallow: Oral glucose — 15–20g fast-acting carbohydrates (glucose tablets, juice, regular soda). Reassess in 15 minutes.

Unconscious or unable to swallow: Do not give anything by mouth. ALS: 25g dextrose (D50) IV, or glucagon 1mg IM if IV access not available. BLS: glucagon IM if carried, 911 if not.

Hypoglycemia responds quickly to treatment — a patient who was combative and unresponsive can be fully alert within minutes of dextrose administration.

Hyperglycemia (High Blood Sugar)

Hyperglycemia itself is not an acute emergency unless it has led to one of two serious complications:

Diabetic Ketoacidosis (DKA)

Primarily in Type 1 diabetes. Without insulin, cells can't use glucose and begin breaking down fat, producing ketones — acidic byproducts that accumulate in the blood.

Signs: Kussmaul respirations (deep, rapid breathing), fruity breath odor (ketones), nausea/vomiting, abdominal pain, dehydration, altered mental status. Blood glucose is usually 250–800 mg/dL.

EMS management: IV fluid resuscitation, 911 transport. Insulin correction happens in the hospital.

Hyperosmolar Hyperglycemic State (HHS)

Primarily in Type 2 diabetes. Severe hyperglycemia (often >600 mg/dL) with profound dehydration but without significant ketosis. Altered mental status, extreme thirst, neurological deficits. High mortality.

EMS management: IV fluid resuscitation, rapid transport.

Hypoglycemia vs. Hyperglycemia at a Glance

| Feature | Hypoglycemia | Hyperglycemia | |---|---|---| | Onset | Rapid (minutes to hours) | Gradual (hours to days) | | Skin | Pale, diaphoretic | Flushed, dry | | Breathing | Normal | Kussmaul (deep, rapid) | | Breath odor | Normal | Fruity (DKA) | | Blood glucose | <70 mg/dL | >250 mg/dL | | Treatment | Glucose | Fluids + hospital |

When in doubt in the field: check a blood glucose. Always carry a glucometer.