What is the initial treatment for a diabetic patient experiencing severe hypoglycemia, particularly if they are unconscious or unable to swallow?

Glucagon for Severe Hypoglycemia

For unconscious diabetic patients or those unable to swallow, immediately call emergency services and administer glucagon 1 mg intramuscularly, subcutaneously, or intranasally if IV access is unavailable—this is the definitive first-line treatment when intravenous dextrose cannot be given. 1, 2

Immediate Management Algorithm

Step 1: Assess Consciousness and Ability to Swallow

• If conscious and able to swallow: Give 15-20g of oral glucose (preferred) or any carbohydrate containing glucose 1
• If unconscious, seizing, or unable to follow commands/swallow: Proceed immediately to parenteral treatment 1, 2

Step 2: Activate Emergency Services

• Call 9-1-1 immediately for any patient with severe hypoglycemia who is unconscious, exhibits seizures, or cannot protect their airway 1, 2
• Critical pitfall: Never attempt oral glucose administration in unconscious patients—this risks fatal aspiration even via buccal or sublingual routes 2

Step 3: Administer Parenteral Treatment

If IV access is available:

• Give intravenous dextrose as the preferred route 2
• Administer 5g aliquots (50 mL of 10% dextrose) IV over 1 minute, repeating every minute until symptoms resolve or blood glucose exceeds 70 mg/dL, maximum 25g total 3

If IV access is NOT available:

• Glucagon 1 mg via intramuscular, subcutaneous, or intranasal route 1, 2, 4
• For children: 30 mcg/kg subcutaneously to maximum 1 mg (or 10 mcg/kg for less nausea, though 20-minute glucose levels are similar) 1
• Expect blood glucose increase within 5-15 minutes, but anticipate nausea and vomiting 1, 4

Step 4: Position and Monitor

• Turn the unconscious person on their side to prevent aspiration when they awaken, as vomiting is common 4
• Recheck blood glucose after 15 minutes 2, 3
• If no response after 15 minutes, administer another dose if available 4

Step 5: Post-Recovery Care

• Once awake and able to swallow safely, immediately provide oral carbohydrates—both fast-acting (regular soft drink, fruit juice) and long-acting sources (crackers with cheese or meat sandwich) 4
• This meal is essential to restore liver glycogen and prevent recurrent hypoglycemia 2
• Monitor blood glucose every 1-2 hours if insulin infusion is ongoing 3

Glucagon Formulations and Administration

Traditional glucagon kit limitations:

• Requires reconstitution of dry powder with sterile water before injection, which is complex during emergencies 4, 5
• Must be used immediately after mixing; cannot be stored 4

Newer formulations with easier administration:

• Intranasal glucagon: needle-free nasal applicator, equally effective as injectable forms 5, 6
• Ready-to-use auto-injector devices (Gvoke HypoPen): no reconstitution required 7, 5
• Dasiglucagon: stable liquid formulation, ready-to-inject, similar potency to native glucagon 7

Who Should Have Glucagon Prescribed

Glucagon should be prescribed for all patients at increased risk for clinically significant hypoglycemia (blood glucose <54 mg/dL). 1

Family members, roommates, school personnel, child care providers, correctional staff, and coworkers must be trained on glucagon location and administration—glucagon use is not limited to healthcare professionals. 1, 4

Special Populations and Considerations

Children and adolescents:

• Severe hypoglycemia in children <5 years may cause cognitive deficits, requiring higher blood glucose goals for this age group 1
• Recognition of hypoglycemia symptoms is developmental and age-dependent 1

Patients with neurologic injury:

• Consider treating blood glucose below 100 mg/dL rather than the standard 70 mg/dL threshold 3

Sulphonylurea-induced hypoglycemia:

• Always requires hospitalization with prolonged IV glucose infusion due to extended drug half-life, unlike insulin-related hypoglycemia which can often be managed at home 8

Critical Post-Event Actions

• Notify the physician immediately after any severe hypoglycemia episode—diabetes medication doses likely need adjustment 4
• Patients with hypoglycemia unawareness or clinically significant hypoglycemia should raise glycemic targets for several weeks to partially reverse unawareness and reduce future episode risk 1
• Severe hypoglycemia is independently associated with 3-fold increased mortality risk and requires complete reevaluation of the diabetes management plan 2, 3