When you find an unresponsive diabetic patient, the first priority is determining whether their blood sugar is too low or too high, because the two emergencies require opposite responses. Low blood sugar (hypoglycemia) is the more immediately life-threatening cause and the one you can treat fastest in the field. High blood sugar emergencies, like diabetic ketoacidosis or hyperosmolar hyperglycemic state, require hospital-level care. In either case, call for emergency medical help immediately.
Start With the Basics: Airway, Breathing, Circulation
Before thinking about blood sugar, ensure the patient has an open airway, is breathing, and has a pulse. Position the patient on their side if they’re breathing but unresponsive, which helps prevent aspiration if they vomit. This is especially important because both high and low blood sugar emergencies can cause nausea and vomiting.
One critical rule: never attempt to give an unconscious person anything by mouth. Oral glucose gels, juice, or sugar tablets are contraindicated in patients who cannot protect their own airway. The risk of choking or aspirating fluid into the lungs is high, and consciousness levels in hypoglycemic patients can shift rapidly.
Check Blood Sugar If You Can
If a glucose meter is available and you’re trained to use it, a fingerstick reading is the single most useful piece of information you can get. The key threshold is 70 mg/dL (3.9 mmol/L).
- Below 70 mg/dL: The patient is hypoglycemic. Administer glucagon if available. Do not give insulin.
- Above 70 mg/dL: The cause of unresponsiveness may be severe hyperglycemia or something else entirely. Wait for emergency medical services. Do not give sugar.
Severe hypoglycemia, sometimes defined as blood sugar below 54 mg/dL (3.0 mmol/L), is a level where the brain no longer has enough fuel to function normally. At this stage, the person typically cannot help themselves and needs someone else to intervene. A reading below 40 mg/dL (2.2 mmol/L) is a medical emergency that can lead to seizures, brain damage, or death without treatment.
Physical Clues That Point to the Cause
When you don’t have a glucose meter, the patient’s body offers clues. These aren’t foolproof, but they can help you make a faster judgment call.
A hypoglycemic patient often looks pale, feels cool and clammy to the touch, and may be sweating heavily. Onset is typically rapid, sometimes within minutes. The patient may have been fine a short time ago. Trembling, confusion, or seizure-like activity may have preceded the loss of consciousness.
A hyperglycemic patient tends to present differently. The skin is often warm and dry. The mouth may be very dry, and you might notice a fruity or sweet smell on their breath, which comes from the body breaking down fat for energy and producing acidic byproducts called ketones. Breathing may be deep and labored, a pattern called Kussmaul breathing that the body uses to try to blow off excess acid. High blood sugar emergencies usually develop over hours to days, not minutes. In the case of hyperosmolar hyperglycemic state, symptoms like excessive thirst and frequent urination may have been building for weeks before the person becomes unresponsive.
Giving Glucagon to an Unconscious Patient
Glucagon is the primary treatment for severe hypoglycemia when the patient can’t swallow. It works by signaling the liver to release stored sugar into the bloodstream. It comes in several forms designed to be used by non-medical bystanders.
An injectable glucagon kit requires mixing a powder with a liquid before injecting it into the thigh or upper arm. The standard dose is 1 mg given by injection, which can be repeated after 15 minutes if the patient doesn’t respond. A pre-filled auto-injector version works like an epinephrine pen and requires no mixing.
Intranasal glucagon is even simpler. It’s a dry powder sprayed into one nostril while the other is held closed. The dose is 3 mg, and the patient doesn’t need to inhale it consciously. It absorbs through the nasal lining. If there’s no response, the dose can be repeated.
Most patients begin to regain consciousness within 10 to 15 minutes of receiving glucagon. Once they’re alert enough to swallow safely, give them a fast-acting carbohydrate followed by a more substantial snack to prevent blood sugar from dropping again.
Why It Might Not Be Blood Sugar at All
Diabetes increases the risk of several other conditions that can cause someone to become unresponsive. Stroke is a major one, since diabetes damages blood vessels over time. Sepsis from an uncontrolled infection, kidney failure (uremia), and lactic acidosis, which can be triggered by certain diabetes medications, can all cause altered mental status in a person with diabetes.
This is why checking blood sugar is so valuable. If the reading comes back normal or only mildly elevated, the cause of unconsciousness is likely something other than a blood sugar emergency, and the patient needs a full medical evaluation. Don’t assume that because someone is diabetic, their unresponsiveness is automatically diabetes-related.
Two Types of High Blood Sugar Emergencies
Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) are the two major high blood sugar crises, and they look somewhat different in an unresponsive patient.
DKA is more common in people with type 1 diabetes. It develops over hours and features the hallmark fruity breath, deep rapid breathing, dehydration, abdominal pain, and rapid heart rate. The body is producing dangerous levels of acid because it can’t use glucose for energy and is burning fat instead.
HHS is more common in type 2 diabetes and tends to develop over days to weeks. Blood sugar levels in HHS are often extremely high, sometimes above 600 mg/dL. The dominant features are profound dehydration, confusion progressing to coma, and altered consciousness. Fruity breath and the deep breathing pattern are less prominent because the acid buildup is typically less severe.
Both conditions cause low blood pressure and a fast heart rate. Both require IV fluids and hospital treatment. In the field, your role is to recognize these signs, relay them to emergency services, and keep the patient’s airway clear.
Monitoring After the Patient Responds
If glucagon brings the patient back to consciousness, the job isn’t over. Blood sugar should be rechecked every 15 to 30 minutes for at least one to two hours. Hypoglycemia can recur, especially if the original cause, such as a missed meal, too much insulin, or heavy exercise, hasn’t been addressed. Glucagon depletes the liver’s sugar stores, which means a second episode of low blood sugar is possible once that initial release wears off.
Patients who were treated for severe hypoglycemia typically need several hours of close observation. If the patient doesn’t fully regain alertness after glucagon, or if blood sugar drops again despite treatment, they need emergency department care.