Diabetic Emergencies: Hypo & Hyper

Why this matters

Low sugar can look like a stroke, intoxication, or a psychiatric emergency. Very high sugar can look like sepsis or dehydration. Check the sugar early so you do not start the wrong pathway. The number does not replace the rest of the exam.

Clinical sequence

1. Check the sugar first in altered mental status, seizure, stroke-like findings, or a patient someone calls drunk.
2. If the sugar is low and they can swallow safely, give oral glucose. If they cannot swallow, use IM glucagon or IV dextrose, whichever you carry. Do not put gel in a mouth that cannot protect the airway.
3. Recheck the sugar and the exam. A one-sided deficit that remains after you correct the sugar still follows a stroke pathway.
4. If the sugar is high, support the airway and give fluid per protocol. Do not give insulin in the field unless your system authorizes it. Think about sepsis too. A refusal after low sugar needs a real capacity plan. Waking up is not enough.

Hypoglycemia

• Hypoglycemia means low sugar. Sweat, tremor, confusion, seizure, one-sided deficits, and combativeness can all be low sugar. Teaching often treats a symptomatic reading under 70 mg/dL as low sugar. Use your protocol’s cutoff.
• Risk rises with insulin, missed meals, illness, and alcohol. It also rises with sulfonylurea pills. Those pills push the pancreas to release insulin.
• If the airway is protected and swallowing is safe, oral glucose is reasonable. If there is no IV, IM glucagon is the usual alternative. IV dextrose is used as authorized. Many systems prefer D10 over D50 because it is easier to titrate and less harmful if it leaks out of the vein. Carry and give what your protocol stocks.
• Recheck the sugar and the mental status. Watch for another drop, especially after long-acting insulin or a long-acting pill.
• A refusal after treatment needs capacity, a plan to eat, and the rules in your protocol or from medical control. Do not take a signature from someone who is not oriented.

Hyperglycemia / DKA / HHS Themes

• Hyperglycemia means high sugar. Diabetic ketoacidosis is high sugar, acid in the blood, and dehydration. Breathing is often deep and fast. That pattern is Kussmaul breathing. Hyperosmolar hyperglycemic state is very high sugar and severe dehydration, usually without the same acid. Both can look like sepsis.
• The history may include lots of urination and thirst, a dry mouth, deep fast breathing, a fruity odor that is not always present, and altered mental status.
• Field care is support. Open the airway and give fluid per protocol. Do not treat one sugar number as the whole diagnosis.
• Do not give insulin in the field unless your system explicitly allows it.
• Look for sepsis and other triggers. High sugar can be a stress response, not the main problem.

Key points

• Check the sugar early in altered mental status, seizure, stroke-like symptoms, and an unexplained behavior change.
• A one-sided deficit can be low sugar. If the deficit remains after you correct the sugar, follow the stroke pathway.
• Document the sugar before and after treatment, what you gave, and how they responded.

Common errors

• Putting oral glucose in the mouth of a patient who cannot protect the airway.
• Assuming high sugar explains everything and skipping a sepsis exam.
• Leaving a high-risk patient who may drop again without a solid plan.

Practice

Related: AMS framework.

Sources & Further Study

Named guidelines for further study. They are not clinical orders and do not replace your protocol or medical direction.

• ADA Standards of Care in Diabetes—2025 — treat symptomatic hypoglycemia; <70 mg/dL is a common teaching threshold, not a field order
• NASEMSO National Model EMS Clinical Guidelines
• Symptomatic hypoglycemia is commonly taught around <70 mg/dL. Many EMS systems prefer D10 over D50 for safety when an IV dextrose pathway is used — follow your protocol.
• Your diabetic emergency protocol.