Severe hypoglycemia: what the people around you should do

It is the episode in which you can no longer help yourself. It is also called level 3 hypoglycemia. It is defined by an altered mental or physical state that requires another person's help to resolve the hypoglycemia, whatever the glucose value [1]. It can range from confusion and disorientation to loss of consciousness.

It is the only level defined by its consequence rather than by a glucose measurement. A severe episode always calls for a conversation with your care team, even if it resolved quickly and without after-effects. It is the strongest signal that your treatment plan needs adjusting.

Confusion, unusual behavior, slurred speech and difficulty with simple movements. Lack of coordination, double vision and a drowsiness from which you are hard to wake can also appear. The people around you often notice these signs before you do [2].

During hypoglycemia, the shift from mild to severe can be rapid, especially if you did not feel its first symptoms. The practical rule for the people around you is simple. If you behave strangely and do not answer coherently, they should assume you have hypoglycemia until proven otherwise.

Because of the risk of choking. A patient who is unconscious or confused can no longer swallow properly. As a result, the liquid or the glucose gel can go straight into the lungs. The consequence is a serious pneumonia on top of the hypoglycemia [3].

The rule is absolute and has no exceptions. Glucose is given by mouth only to a fully conscious patient who can swallow on command. In every other situation the correct treatment is glucagon, followed by calling for medical help [1].

Three things, in this order:

• They turn the patient on their side, so that they do not choke [3].
• They give glucagon, if it is available.
• They call emergency services.

What must never be done is to give insulin to a patient with hypoglycemia. Training for the people around you must state this prohibition explicitly. The confusion arises because many people associate diabetes with insulin and believe it always helps [4]. It is the most dangerous mistake someone without medical knowledge can make with a patient with diabetes.

Every time the patient is not fully conscious or cannot swallow [1]. Help is also called if there is no glucagon at hand. Do not wait to see whether things improve on their own.

Help is also called after a seizure, even if the patient seems to have recovered. Other situations that require medical assessment are severe hypoglycemia in a young child, severe hypoglycemia after drinking alcohol, or an episode that recurs within a short time [5]. In these cases the episode can come back once the effect of glucagon wears off.

Yes. Seizures occur when the brain is left without enough glucose for a longer time. They are more common in children and at night, when the episode is not noticed in time [3].

During a seizure, nothing is put in the patient's mouth and no attempt is made to hold them down. Nearby objects are moved away, the patient is turned on their side once the movements stop, and medical help is called. Glucagon can be given even during the seizure, because it is injected subcutaneously or intramuscularly, or sprayed into the nose.

Glucose usually recovers within 10 to 20 minutes after glucagon. The average time to glucose recovery is about 16 minutes for the nasal form and 13 minutes for the injectable form [6]. Your general condition, however, needs more time to recover fully.

Confusion, headache and fatigue can last several hours. Some patients feel weak until the next day [7]. This gap between the glucose value and the general condition matters for the people around you. A patient whose glucose is back to normal may still be unable to drive or to make important decisions. Supervision must continue until behavior is completely normal, not just until the glucometer shows a good value.

Everyone you spend time with regularly. Your family, your partner, your roommates, your coworkers, your coach and the staff at school or kindergarten. No formal medical training is needed to give glucagon when necessary [1].

What each of them needs to know comes down to just four points:

• What severe hypoglycemia looks like.
• The place where the glucagon is kept.
• How to give the glucagon.
• The number to call for help.

Show them the box and let them read the instructions calmly, ahead of time. A five-minute explanation given in advance is worth more than any discussion during the episode [8].

Information saying that you have diabetes and are treated with insulin. It can be a bracelet, a card kept in your wallet next to your ID, or a message on your phone's lock screen. Add a contact number and a note that you use a sensor or an insulin pump [9].

The role of this information is to shorten the time to the right treatment. A confused patient found on the street can be mistaken for someone who is drunk. A written note in plain view completely changes what happens in the first minutes.

Yes. Untreated severe hypoglycemia can lead to loss of consciousness, seizures, coma and, rarely, even death [10]. The indirect risks matter too, such as injuries from falls and road accidents. The risk rises when the episode happens during sleep, when you are alone or after drinking alcohol.

Technology greatly reduces the risk of severe hypoglycemia, but it never removes it completely [11]. Most adults with type 1 diabetes now use a sensor or an automated insulin delivery system. Even so, about one in five patients has at least one severe episode in a given year [12]. These episodes are nevertheless largely predictable. The strongest warning signals are a severe episode in recent months and impaired awareness of hypoglycemia [13]. Both call for a conversation with your doctor, not a fix you work out on your own.