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What to do in a diabetic emergency: understanding the warning signs and treatments

Nurses in every setting need to know the symptoms and treatment for hypoglycaemia, hyperglycaemia and DKA

Nurses in every setting need to know the symptoms and treatment for hypoglycaemia, hyperglycaemia and diabetic ketoacidosis

  • It is estimated that one in 15 people in the UK have diabetes, meaning nurses in every area of healthcare need to understand the condition
  • Severe hypoglycaemia, which occurs when blood glucose levels are too low, can lead to symptoms such as unconsciousness, fitting or the patient becoming aggressive
  • Hyperglycaemia, which occurs when blood glucose levels are too high, can lead to patients developing diabetic ketoacidosis

With 4.7 million people or one in 15 in the UK estimated to have diabetes, nurses are likely to encounter people with the condition often.

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Nurses in every setting need to know the symptoms and treatment for hypoglycaemia, hyperglycaemia and diabetic ketoacidosis

  • It is estimated that one in 15 people in the UK have diabetes, meaning nurses in every area of healthcare need to understand the condition
  • Severe hypoglycaemia, which occurs when blood glucose levels are too low, can lead to symptoms such as unconsciousness, fitting or the patient becoming aggressive
  • Hyperglycaemia, which occurs when blood glucose levels are too high, can lead to patients developing diabetic ketoacidosis
Picture: iStock

With 4.7 million people – or one in 15 – in the UK estimated to have diabetes, nurses are likely to encounter people with the condition often.

This means it is essential to know the fundamentals of what to do when someone with diabetes is in need of urgent help, for example, during hypoglycaemia.

Debbie Hicks

All nurses should be able to help people with hypoglycaemia

Nurse consultant in diabetes Debbie Hicks, who works for primary care provider Medicus Health Partners and is co-chair of Trend Diabetes, a group for diabetes nurses, believes that all nurses should be able to help people with mild or moderate hypoglycaemia.

Hypoglycaemia, also referred to as a ‘hypo’, occurs rapidly when blood glucose levels are too low, usually below 4mmol/l.

It can be caused by a taking too much insulin, excess alcohol consumption, physical exertion and/or missing meals.

Symptoms vary, but include confusion, dizziness, hunger, mood changes and sweating, blurred vision and anxiety, according to Diabetes UK.

‘The prevalence of diabetes is high and people with diabetes are everywhere, in every setting. We want nurses in hospitals, care and nursing homes, GPs and the community to know the common signs and symptoms and know what to do’

Debbie Hicks, co-chair, Trend Diabetes

When it is severe, the person with diabetes can be unconscious or fitting, aggressive or unable to eat. Severe hypoglycaemia is an emergency (see box for more information on guidance from Trend Diabetes if the patient is unconscious).

Severe hypoglycaemia: what to do

When the person with diabetes is unconscious, nurses should:

  • Call 999 and seek urgent medical assistance
  • If the individual is breathing, they should be placed in the recovery position (on their side with their head tilted back). If the individual is not breathing, begin cardiopulmonary resuscitation
  • Glucose treatment should not be put in their mouth
  • Glucagon can be injected if someone is present who is trained to do so
  • Once the individual is conscious and able to eat, give 20g of quick-acting carbohydrate followed by a 20g starch carbohydrate snack

(Source: Trend Diabetes)

Recognising the signs of a patient experiencing a hypo

At the mild or moderate end of hypoglycaemia, nurses should generally aim to support the person with diabetes to self-manage the episode as far as possible.

‘I would hope that all nurses from any setting would be able to recognise the signs of a hypo and know what to do,’ Ms Hicks says. ‘The prevalence of diabetes is high and people with diabetes are everywhere, in every setting. We want nurses in hospitals, care and nursing homes, GPs and the community to know the common signs and symptoms and know what to do.’

Diabetes UK senior clinical adviser Karen Davies agrees that a grasp of the basics is essential for all nurses.

‘Nurses need to know the symptoms of hypos and that the cause is blood glucose levels dropping, but that can be tricky, as not everyone has the same symptoms and some people have no awareness that they are going low,’ Ms Davies says.

‘A nurse should ask someone if they have diabetes, if they do not already know, or if the person can’t answer, look for a medical ID bracelet and ask them if they feel they are having a hypo. The next step for a nurse is how do they support that person going through the low.’

Encouraging patients to self-manage a mild or moderate hypoglycaemia episodes

For mild or moderate hypoglycaemia episodes, ask the person if they are having a hypo and encourage them to self-test their blood if they have a blood glucose monitor with them.

If the person does not have one, Ms Hicks says if the episode is taking place within a general practice there should be a quality-controlled blood glucose meter the nurse can use.

If they test below 4mmol/l or if they have no monitor but say they feel they are having an episode, encourage them to eat 15-20g of fast-acting carbohydrate.

According to Trend Diabetes, this can be one of the following:

  • 60ml Gluco Juice.
  • 200ml (a small carton) of smooth orange juice.
  • Five or six dextrose tablets.
  • Five large jelly babies.
  • Seven small jelly beans.

Two tubes of 40% glucose gel can be inserted slowly into the buccal cavity, if the person is unable or unwilling to take other oral treatments. However, this treatment cannot be given if the person is unable to swallow.

‘A person with diabetes will often carry the snacks that work well for them with them, so ask if they have some in their bag and offer to help find it, with their permission,’ Ms Hicks says.

‘This isn’t always straightforward as people having a hypo can become aggressive or irritable.’

‘With COVID-19, we are finding that some people with type 1 diabetes are not being diagnosed with the condition until they are in diabetic ketoacidosis and are critically ill’

Karen Davies, senior clinical adviser, Diabetes UK

After they have eaten their snack, wait for 15 minutes for the glucose to take effect. If the person does not feel better (or if the blood glucose level is still less than 4 mmol/l), repeat one of these treatments to a maximum of three times.

If after three treatments the blood glucose is still low, seek urgent medical advice, Trend Diabetes guidance says.

‘We keep a hypo box in all the 15 GP surgeries that I work with,’ Ms Hicks says. ‘Each box contains a blood glucose monitor, dextrose tables and other forms of glucose, and a packet of digestives. It has everything to help someone over a mild or moderate hypo and I would like to see them much more widely available.’

If unclear whether the person has diabetes, check for a medical alert bracelet Picture: iStock

It is important to monitor blood glucose levels after a hypo

When the individual feels better, they should eat a small starchy snack, such as a banana, a slice of bread or two plain biscuits, to prevent their blood glucose level slipping back down, and be given their usual medications.

Blood glucose levels should be regularly monitored following an episode of hypoglycaemia to determine blood glucose trends and avoid a second episode.

Ms Hicks says that when someone feels better or has reached 4mmol/l, they should be able to self-manage.

Nurses should be aware that some people, especially older people living with frailty, are often not as easily able to identify if they are having an episode of hypoglycaemia as younger people, Ms Hicks says. So, their blood glucose level could be lower by the time they spot the symptoms.

Three diabetic emergencies: hypoglycaemia, hyperglycaemia and DKA

Hypoglycaemia

Hypoglycaemia is a lower than normal level of blood glucose, usually considered to be below 4mmol/l.

Hypoglycaemia may occur when people with diabetes eat less during or after exercise and prevalence may increase with certain medications such as sulphonylureas, prandial glucose regulators (Meglitinides) or insulin, or with contraindications with other medications that are taken.

It is recommended that a blood glucose level of less than 4mmol/l should always be treated.

Common early symptoms include sweating, palpitations, shaking, hunger, anxiety, paraesthesia and general malaise.

Later symptoms include confusion, drowsiness, unusual behaviour, speech difficulties, lack of coordination and coma.

Hyperglycaemia

Hyperglycaemia, or a hyper, can happen when blood glucose levels are too high, usually above 7mmol/l before a meal and above 8.5mmol/l two hours after a meal, according to Diabetes UK.

Causes can include a missed a dose of medication, too much carbohydrate, being stressed, being unwell from an infection and having overtreated a hypo.

When levels are slightly high there are not many symptoms, but as they get higher people may find they are passing more urine than usual, are thirsty, have headaches, and feel tired and lethargic.

Diabetic ketoacidosis

Diabetic ketoacidosis (DKA) is serious and needs to be treated quickly. It happens when there is severe lack of insulin in the body. This means the body is unable to use sugar for energy and starts to use fat instead, leading to ketones being released.

If left unchecked, ketones can build up and make the blood become acidic, hence the name ketoacidosis.

Symptoms include high blood sugar levels, being thirsty, needing to urinate more often, feeling tired, sleepy and/or confused, blurred vision, stomach pain, feeling or being sick, passing out, and sweet or fruity-smelling breath (like pear drops).

People with suspected DKA should go to an emergency department straight away for emergency care, the NHS says.

(Sources: Trend Diabetes, Diabetes UK )

Being aware of problems caused by hyperglycaemia

Hyperglycaemia occurs when blood glucose levels are too high. It can be caused by physical and psychological stress, as stress hormones cause the level of glucose in the blood to rise.

It can also be a result of missing medication, having an infection or from having eaten sweet or starchy food.

While responding to hyperglycaemia is generally less time-critical than for a hypo, recognising the symptoms of hyperglycaemia are important for people with diabetes. If their blood glucose is slightly high for a short time, emergency treatment won’t be necessary, Diabetes UK says.

Karen Davies, Diabetes UK senior clinical adviser

But if it continues to rise then healthcare professionals or the person affected may need to act fast to avoid them developing diabetic ketoacidosis (DKA).

For people with diabetes whose blood glucose level is 15 mmol/l or more, advise that they check their blood or urine for ketones. If ketones are present, it is likely they do not have enough insulin and may need to increase their dose or give themselves an extra dose.

‘When we talk about hypers and emergencies, we mainly mean DKAs,’ says Ms Davies. ‘With COVID-19 we are finding that some people with type 1 diabetes are not being diagnosed with the condition until they are in DKA and they are critically ill.’

Consider undiagnosed type 1 diabetes

Nurses need to be alert to the signs of diabetes in people of all ages, especially children, in case they have undiagnosed type 1 and are heading for DKA, Ms Davies says. Type 1 needs to be diagnosed promptly and managed with insulin.

Diabetes UK advises people look out for the 4Ts:

  1. Toilet (urinating more).
  2. Thirst.
  3. Tiredness.
  4. Thinner (weight loss).

‘We need to get the message across, especially during COVID-19, when people may not seek medical advice or have the same access to services, that these symptoms suggest type 1 diabetes and need to be acted on straight away,’ says Ms Davies.

‘If there are any signs of DKA, or the need for fluids or stabilisation, that must be done in a hospital. Any cases that cause nurses concern around potential undiagnosed type 1 or DKA symptoms must be escalated immediately in any setting.’

Risk of diabetes complications

Meanwhile people whose blood glucose levels consistently run high should be referred for specialist support as this puts them at higher risk of serious diabetes complications.

‘When blood glucose levels rise it is usually to do with too much food or not enough exercise,’ Ms Hicks says.

‘It can also be when people are unwell. Diabetes teams should always try to provide education for people with diabetes about what to do when ill, and they should have been given their sick day rules. Drinking plenty of fluids is important as we want people to stay hydrated when their blood glucose levels are too high.’

Diabetes emergencies quiz: test your knowledge

(Answers at the end of the article)

Jelly babies provide fast-acting carbohydrate. Picture: iStock

A person is considered to have hypoglycaemia when the blood glucose level dips below what level?

A Below 3mmol/l

B Below 4mmol/l

C Below 5mmol/l

How much fast-acting carbohydrate do people need initially when experiencing hypoglycaemia?

A 15 to 20g

B 20 to 25g

C 25 to 30g

Which of the following is the right amount of fast-acting carbohydrate to give initially in an episode of hypoglycaemia?

A Five large jelly babies

B Seven small jelly beans

C Five or six dextrose tablets

D All of the above

How long should the wait be between eating the fast-acting carbohydrate and retesting the blood glucose level?

A 15 minutes

B 30 minutes

C 45 minutes

At what blood glucose level should a person with diabetes test their blood or urine for ketones?

A 10mmol/l

B 13mmol/l

C 15mmol/l

At what point is blood glucose level generally considered too high before a meal?

A 6mmol/l

B 7mmol/l

C 8mmol/l


Further information



Quiz answers

B,A,D,A,C,B


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