💉 Severe Hypoglycemia: When Low Blood Sugar Becomes an Emergency

Hypoglycemia — low blood sugar — can usually be fixed by eating a few glucose tablets or drinking some juice. But when blood sugar drops so low that a person cannot eat or drink, becomes unconscious, or has a seizure, it crosses the line into severe hypoglycemia. This is a life‑threatening emergency that requires immediate action. Dr. Ravi Sishir Reddy explains the causes of severe hypoglycemia, how to recognise it, and the step‑by‑step use of glucagon — the emergency hormone injection that can save a life.

1. What Is Severe Hypoglycemia?

Severe hypoglycemia is defined as a blood glucose event in which the person is unable to treat themselves because of altered consciousness, confusion, or seizures. They need help from another person. The exact blood sugar level varies from person to person, but severe symptoms usually appear when glucose falls below 40‑50 mg/dL. Severe hypoglycemia is most common in people on insulin or sulfonylureas, and it can happen suddenly — sometimes with little or no warning.

2. What Causes Severe Hypoglycemia?

• Too much insulin or sulfonylurea: An excessive dose, a miscalculation, or overlapping doses.
• Skipped or delayed meals after taking mealtime insulin.
• Unplanned or intense exercise without adjusting medication or eating extra carbohydrates.
• Alcohol consumption: Especially on an empty stomach; alcohol blocks the liver from releasing stored glucose for hours.
• Vomiting or severe diarrhoea that prevents absorption of food.
• Kidney disease that reduces insulin clearance.
• Hypoglycemia unawareness: Some people no longer feel the early symptoms of a low, and their blood sugar can drop dangerously low without them realising it.

3. Recognising Severe Hypoglycemia in Yourself or Someone Else

The person may exhibit a progression of symptoms:

• Confusion, irritability, or unusual behaviour (may appear drunk).
• Slurred speech and poor coordination.
• Extreme drowsiness and difficulty staying awake.
• Inability to follow simple instructions or swallow safely.
• Seizures or convulsions.
• Loss of consciousness.

If you are with someone who has diabetes and they become confused, unresponsive, or have a seizure — do not try to force them to eat or drink. They could choke or aspirate. Instead, take emergency action immediately.

4. Glucagon: What It Is and How It Works

Glucagon is a hormone made by the pancreas that does the opposite of insulin — it tells the liver to release its stored glucose into the blood. A glucagon emergency kit contains a synthetic version of this hormone. When injected into a person with severe hypoglycemia, glucagon raises blood sugar within 5‑15 minutes by releasing the liver's glycogen stores. It is the standard rescue treatment for severe hypoglycemia and should be kept at home, at work, and in the car by anyone on insulin or high‑risk medications. Family members, coworkers, and school staff should be trained to use it.

5. Step‑by‑Step Guide: How to Use a Glucagon Emergency Kit

There are two main types: the traditional injection kit (powder and diluent that must be mixed) and the newer nasal glucagon (Baqsimi — a ready‑to‑use powder sprayed into the nose). Both are effective. Dr. Reddy describes the injection method, as it is more widely available in India:

1. Remove the cap from the vial of glucagon powder and the syringe of diluent.
2. Inject the entire contents of the syringe into the vial.
3. Gently swirl the vial until the powder dissolves completely and the solution is clear. Do not shake vigorously.
4. Draw the prescribed dose back into the same syringe. For adults, the entire vial (1 mg) is usually given. For children under 25 kg, a half dose (0.5 mg) is typical — check the kit instructions.
5. Inject into a large muscle — the thigh (front or outer side) or the upper arm — through clothing if necessary. The injection is intramuscular, not into a vein.
6. After injection, turn the person onto their side (recovery position). They may vomit as the glucagon takes effect.
7. Once the person is awake and able to swallow (usually within 10‑15 minutes), give them a fast‑acting sugar (juice, glucose tablets) followed by a longer‑acting snack (crackers and cheese, a sandwich, or a bowl of cereal) to prevent recurrence.
8. If there is no response within 15 minutes, a second dose may be given if available, and an ambulance must be called immediately.

For nasal glucagon (Baqsimi): Remove the device from its tube, insert the tip into one nostril, and press the plunger. No inhalation is required. The absorption is rapid and works similarly to injected glucagon.

6. After Severe Hypoglycemia: What Next?

Even if the person recovers fully, they should see their doctor within the next 24 hours. The event may indicate that their insulin dose or medication regimen needs adjustment. The cause of the severe low should be investigated — was it a miscalculated dose, a missed meal, unexpected exercise, or alcohol? People who experience frequent severe hypoglycemia may benefit from a continuous glucose monitor (CGM) with low‑glucose alarms or a change in their insulin type. Recurrent severe hypos can lead to hypoglycemia unawareness, creating a vicious cycle that must be broken.

7. Preventing Severe Hypoglycemia

• Check blood sugar regularly: Especially before driving, before exercise, and before bed.
• If you have hypoglycemia unawareness: Set higher glucose targets temporarily (e.g., 100‑150 mg/dL) to retrain the body's warning signals. Use a CGM.
• Always carry fast‑acting carbs: Glucose tablets, juice, or a sugary snack should be with you at all times.
• Educate your family and close contacts: Ensure they know how to recognise severe hypoglycemia and how to use the glucagon kit.
• Review your insulin doses with your doctor whenever there is a change in diet, weight, or exercise habits.
• Limit alcohol and never drink on an empty stomach.
• Consider a service dog: Some trained dogs can detect low blood sugar and alert their owner or family members, providing an extra layer of safety.