“You don’t know what you’re talking about!” yelled the woman across the school gymnasium at my recently certified, newly recruited first aid course instructor. Her words hung heavily in the shocked silence.

The instructor, unsure how to handle this awkward situation, turned to me for guidance. I called a short break and asked the students to return in 10 minutes. Meanwhile, recognizing the woman’s uncharacteristic behaviour was a sign of low blood sugar, a friend sitting beside her offered her some candy. After a few minutes, the woman felt better and apologized profusely for her rudeness.

Aggressive behaviour is just one of the signs of a diabetic emergency. For those with diabetes, a sudden drop or rise in blood sugar levels can quickly progress to a life-threatening emergency. Even if you don’t know it, odds are there’s someone in your life living with diabetes.

Worldwide, 540 million people (one in ten adults) live with diabetes, according to the International Diabetes Federation. The organization predicts this will rise to one in eight or 783 million by 2045. Some 240 million people are estimated to be living with undiagnosed diabetes — a significant cause of lower limb amputation, blindness, kidney failure, heart attacks and stroke.

You don’t need to be a doctor to help a person suffering from a diabetic emergency, but providing effective first aid requires understanding diabetes basics. Being prepared by learning to recognize the signs and symptoms and the appropriate treatment enables us to provide swift assistance and potentially save a life.

What is a diabetic emergency?

Diabetes mellitus is a disease in which the body cannot process glucose (sugar) in the bloodstream. The body needs a hormone called insulin to process sugar. Produced by the pancreas, insulin helps glucose move from the bloodstream into the cells for energy. In cases where the pancreas can no longer produce insulin or the body can’t effectively use insulin, diabetes results. When a person has diabetes, their body cannot maintain blood sugar within a normal range.

The woman in our first aid class may have been running late and skipped breakfast or felt uncomfortable having a snack during the class and waited a little too long to eat, resulting in a drop in blood sugar.

“Diabetes mellitus is due to a deficiency of the internal secretion of the pancreas, said Frederick Banting, recipient of the 1923 Nobel Prize in Physiology or Medicine with John Macleod, for discovering insulin and its therapeutic potential. “The main principle of treatment is, therefore, to correct this deficiency.”

Diabetes is a complex condition that can take many different forms. As well as the more commonly known type 1, type 2 and gestational diabetes, there are a range of other forms of the disease. A person with diabetes may manage their condition with oral medication or insulin injections. Diet and exercise also play an essential role.

Regardless of the type or cause of diabetes, a diabetic emergency occurs when blood glucose rises or falls outside the normal range. In either of these situations, insufficient glucose reaches the brain, leading to a deterioration of the person’s mental state. The two main types of diabetic emergencies are hypoglycemia and hyperglycemia.

Hypoglycemia, or too little sugar in the blood, occurs when the insulin level is too high relative to the blood sugar level. It happens if someone misses a meal or snack, eats less or exercises more than usual, vomits or takes too much medication. The small amount of sugar in the blood gets used up quickly, and the brain does not receive the level of sugar it needs. This results in an acute condition that can lead to a loss of consciousness or death if not treated promptly. Hypoglycemia develops quickly and is the cause of most diabetic emergencies.

A diabetic crash is also known as diabetic shock or insulin shock and is caused by severe hypoglycemia. A person’s symptoms may progress from headache, irritability, dizziness, sweating, trembling, hunger and anxiety to feeling confused — as we saw firsthand with the first aid course student — to having trouble speaking, experiencing double vision, or even losing consciousness.

Though hypoglycemia is common in people who have diabetes, it can also occur for other reasons in people without diabetes. Failing to treat severe low blood sugar can be life-threatening.

Hyperglycemia occurs when there is too much sugar in the blood when a person with diabetes overeats, takes too little medication, exercises less than usual, has an infection or experiences physical or emotional stress. With hyperglycemia, the body cells cannot get the sugar they need, even when sugar is abundant in the body. The body breaks down other food sources to meet its energy needs, causing waste products to build up and making the person ill. It may also cause the person’s breath to have a fruity or sweet odour. Hyperglycemia can lead to a diabetic emergency known as diabetic coma.

Hyperglycemia is also referred to as an insulin or glucose spike. Often, people experiencing this feel tired, thirsty and hungry, but some don’t have symptoms or know when they are spiking. As glucose rises, the body releases insulin to manage the extra glucose. If a person’s blood sugar is excessively or consistently high, they may feel thirsty, have blurred vision, and headaches. Diabetes can result in perilously high blood sugar levels and, if not controlled, results in serious complications. Hyperglycemia tends to develop slowly, though and is, therefore, less likely to become a first aid emergency.

It’s hard to tell the difference between hypo and hyperglycemia, as many of the signs and symptoms overlap. The good news is that the first aid treatment is the same for both.

First aid for a diabetic emergency

During a Red Cross first aid class, you learn to follow a protocol for first aid emergencies known as Check, Call, Care. This procedure includes checking for dangers, checking the person and providing care. Covering the full protocol from start to finish is beyond the scope of this article, so here, we will focus on first aid for a suspected diabetic emergency. I’m sharing guidelines from the Canadian Red Cross Comprehensive Guide for First Aid & CPR.

How can you tell if a person’s blood sugar is high or low?
If a glucometer is available, having the person check their blood sugar will show if they have hyperglycemia or hypoglycemia. However, you may not have access to this equipment. Without measuring blood glucose levels, it’s hard to tell which type of diabetic emergency a person is suffering from, as the symptoms can be similar.

What to look for
If the person is conscious and you’re confident you’ve addressed any life-threatening conditions, you must check for any less obvious conditions. When trying to assess whether a person is suffering from a diabetic emergency, look for:

• Changes in the level of responsiveness (drowsiness, unconsciousness).
• Changes in behaviour (confusion, irritability, or aggression).
• Rapid breathing or difficulty breathing.
• Cool, clammy or sweaty skin.
• Skin paler than usual. It’s easier to assess this if you know the person.
• Appearance of intoxication (slurred speech, difficulty walking)
• Feeling and looking ill (dizziness, weakness or shakiness).
• Seizures.
• Fruity, sweet breath odour.
• Look carefully for medical alert jewelry like a bracelet or necklace. Check the person’s belongings for information about medical conditions, such as prescriptions, medical cards or, especially for the insulin-dependent diabetic, syringes. If, after your assessment, you suspect the person is suffering a diabetic emergency:

Call Emergency Medical Services (EMS) if:

• You can’t give the person sugar.
• The person is not fully awake.
• The person has a seizure.
• The person doesn’t feel better within 10 minutes of having sugar.
• Care for the person

If the person cannot follow simple commands, swallow safely, or is unresponsive, confirm that EMS has been called and place them on their side. This recovery position helps keep their airway clear.

If the person can follow simple commands, answer questions, and swallow safely, offer them 15 to 20 grams of sugar. Check package labels to figure out how much to give. The following are the forms of sugar the Red Cross recommends to give, listed in order of preference:

• Oral glucose tablets.
• Chewable candy.
• Fruit juice.
• Fruit strips.
• Milk.
• Other forms of sugar, such as a non-diet soft drink or a spoonful of sugar mixed into a glass of water.

Then, continue monitoring the person for the next 10 minutes. If their condition deteriorates or does not improve within 10 minutes, call EMS and give them more sugar if they are still conscious and it’s safe to do so. If the person feels better, recommend they eat a complete meal. If low blood sugar is responsible for the person’s symptoms, ingesting sugar will improve their condition. If their blood sugar is too high, having them swallow 15 to 20 grams of sugar won’t harm them in the short term and can be addressed later with their doctor.

First aid does not include administering insulin. A medical professional should investigate the cause of the emergency to determine whether insulin is the correct treatment.

Overall, rates of diabetic emergencies are increasing. The chances are you have a family member or friend living with diabetes, so it’s in everyone’s interest that we have a basic understanding of diabetes and how to assist someone experiencing a diabetic emergency.

Your local Red Cross first aid course provider offers public first aid and CPR classes where you can learn the skills you need to act quickly and effectively in emergencies. The few dollars you pay for the training may be the best investment you ever make. The most precious gift you can give is saving a person’s life.

The incident with the woman in the first aid class provided a learning opportunity for me, the course instructor, and the participants. It taught me to remind my trainee instructors to reassure students at the start of class to snack if they need to during the session.

If you suspect a person is having a diabetic emergency and they are conscious, give them sugar. If their blood sugar is too high, you won’t harm them. If their blood sugar is too low, giving them sugar may save their life.

Learn more about other medical emergencies in a Red Cross Standard First aid class.