What is the best course of treatment for a patient with hypoglycemia (low blood sugar) whose blood glucose levels have dropped to the 30s?

Blood Sugar in the 30s: Immediate Treatment Protocol

For blood glucose in the 30s (severe hypoglycemia), immediately administer 15-20 grams of glucose orally if the patient is conscious and able to swallow, or give 1 mg intramuscular/subcutaneous glucagon (or 10-20 grams IV dextrose 50% if IV access available) if the patient has altered mental status or cannot swallow safely. 1, 2, 3

Immediate Action Based on Mental Status

If Patient is Conscious and Can Swallow

• Administer 15-20 grams of pure glucose immediately (glucose tablets are preferred over juice, gel, or other carbohydrates because glucose raises blood sugar more effectively than fructose or galactose-containing alternatives). 1, 4
• Recheck blood glucose after 15 minutes—if still below 70 mg/dL, repeat the 15-20 gram dose. 1, 2
• Once blood glucose trends above 70 mg/dL, provide a meal or snack containing protein and complex carbohydrates to prevent recurrence. 1, 2

If Patient Has Altered Mental Status or Cannot Swallow

• Administer 1 mg glucagon intramuscularly or subcutaneously into the upper arm, thigh, or buttocks immediately—family members and caregivers can and should do this; it is not limited to healthcare professionals. 1, 2, 3
• If IV access is available, give 10-20 grams of IV dextrose 50% instead, titrated based on the initial glucose value. 2
• Never attempt oral glucose in an unconscious patient due to aspiration risk. 2
• Call emergency services immediately after administering treatment. 2, 3
• If no response after 15 minutes, administer a second dose of glucagon (1 mg) or IV dextrose while waiting for emergency assistance. 2, 3

Critical Monitoring Parameters

• Stop any insulin infusion immediately when treating hypoglycemia. 2
• Recheck blood glucose every 15 minutes until it stabilizes above 70 mg/dL. 1, 2
• Avoid overcorrection that causes rebound hyperglycemia—target glucose >70 mg/dL but not excessively high. 2
• Continue monitoring every 1-2 hours if the patient is on insulin infusion. 2

Why Glucose in the 30s is Dangerous

Blood glucose below 54 mg/dL (Level 2 hypoglycemia) represents the threshold where neuroglycopenic symptoms begin—including confusion, seizures, loss of consciousness, and inability to self-treat. 1 This requires immediate external assistance and emergency intervention. 2 Prolonged or recurrent severe hypoglycemia can cause permanent neurological damage, particularly in young children. 5

Common Treatment Pitfalls to Avoid

• Do not use glucose gel or orange juice as first-line treatment—they are significantly less effective than glucose tablets or solution at raising blood sugar within 10-15 minutes. 1, 4
• Avoid treating with chocolate, candy bars with nuts, or milk—added fat retards glucose absorption and delays recovery. 6
• Do not use buccal glucose in unconscious patients—absorption through oral mucosa is negligible (less than 0.1 mg absorbed), making it ineffective. 2, 7
• Do not delay treatment to document blood glucose if severe hypoglycemia is suspected based on symptoms—treat first, then confirm. 5

Post-Recovery Management

• Once the patient regains consciousness and can swallow, immediately give 15-20 grams of oral fast-acting carbohydrates, followed by long-acting carbohydrates to restore liver glycogen and prevent recurrence. 2, 3
• Any episode of severe hypoglycemia requires reevaluation of the diabetes management plan, including medication regimen adjustments, insulin timing relative to meals, and identification of precipitating factors (missed meals, excessive insulin dose, unusual physical activity, alcohol consumption). 2, 5, 6
• Consider admission to a medical unit for observation and stabilization if hypoglycemia is unexplained or recurrent. 2

High-Risk Features Requiring Intensive Monitoring

• History of recurrent severe hypoglycemia or hypoglycemia unawareness. 2, 8
• Concurrent illness, sepsis, hepatic failure, or renal failure. 2
• Recent reduction in corticosteroid dose or altered nutritional intake. 2
• Endogenous insulin deficiency with compromised glucose counterregulation (deficient glucagon and epinephrine responses). 8

Prevention and Patient Education

• Prescribe glucagon for home use and train family members on administration for all patients at risk of severe hypoglycemia. 1, 2
• Educate patients to always carry fast-acting glucose sources (glucose tablets preferred). 2, 6
• Recommend medical identification indicating diabetes and hypoglycemia risk. 2
• Advise patients on situations that increase hypoglycemia risk: fasting for tests, delayed meals, intense exercise, alcohol consumption, and sleep. 2