23.11 — Diabetic and Seizure Emergencies

Someone is confused, sweating, aggressive and slurring their words.

The most common assumption is that they are drunk. People have been arrested, put in police cells and left to sleep it off — and died, because their blood glucose was 1.8 and a spoonful of sugar would have fixed it in five minutes.

Low blood glucose is one of the few genuine medical emergencies that a bystander can completely reverse, with something from a kitchen cupboard, in minutes.

And the rule that makes it safe: if you do not know whether the glucose is high or low, treat as if it is low.

Treating a high glucose as low causes almost no harm — a little more sugar in someone already high changes very little over the minutes involved. Failing to treat a low can cause brain damage or death.

Hypoglycaemia — low blood glucose

Blood glucose below 4 mmol/L (around 70 mg/dL).

"Four is the floor" is the phrase used in diabetes education, and it is worth knowing.

Why it matters so much

The brain runs almost exclusively on glucose (Chapter 11.2).

Unlike muscle, it cannot use fat for fuel, and it holds almost no reserve of its own.

So when circulating glucose falls, brain function fails within minutes — and prolonged severe hypoglycaemia causes permanent damage.

This is why it is an emergency measured in minutes rather than hours.

Who gets it

People on insulin — type 1 diabetes, and type 2 on insulin.

People on sulfonylureas — gliclazide, glimepiride (Chapter 22.8). And these deserve emphasis: sulfonylurea hypoglycaemia can be prolonged and can recur for many hours, so anyone who has had a significant hypo on one of these needs hospital observation rather than just a biscuit.

Metformin, SGLT2 inhibitors, GLP-1 agonists and DPP-4 inhibitors do not cause hypoglycaemia on their own, which is a useful thing to know.

Also: alcohol, particularly with little food, because it blocks the liver's production of glucose; severe illness; liver failure; adrenal insufficiency; and after bariatric surgery.

The triggers in someone with diabetes: too much insulin, a missed or delayed meal, unusual exercise, alcohol, and hot weather, which increases insulin absorption.

And exercise-related hypos can occur up to 24 hours afterwards, as muscle replenishes its glycogen stores.

Recognising it

Early — adrenaline symptoms, as the body responds to falling glucose:

Sweating, trembling, palpitations, hunger, anxiety, tingling around the lips, and pallor.

Later — the brain running out of fuel:

Confusion, difficulty concentrating, slurred speech, unsteadiness, blurred vision, odd or out-of-character behaviour, aggression, drowsiness, seizures, and unconsciousness.

Two things that make this harder in practice:

It genuinely looks like drunkenness. Confusion, slurred speech, unsteadiness and aggression — with the sweating being the clue that distinguishes it, along with a medical alert bracelet or an insulin pen in a pocket.

Impaired awareness of hypoglycaemia. Some people with long-standing diabetes lose the early warning symptoms entirely, and go from feeling normal to being confused without any warning phase. They are at much higher risk and are usually known to their diabetes team.

And a hypo during sleep may present as nightmares, night sweats, or waking with a headache and feeling terrible.

Treatment — exactly

If they are conscious and can swallow safely:

1. Give 15 to 20 grams of fast-acting carbohydrate.

Which in practice means:

4 to 5 glucose tablets.A small glass (about 150 to 200 ml) of ordinary fruit juice or non-diet fizzy drink.A tube of glucose gel.5 to 7 jelly babies or similar sweets.Or 3 to 4 teaspoons of sugar in water.

Do not use chocolate, biscuits or anything with a high fat content. Fat slows gastric emptying, so the sugar arrives too slowly — which is the reason the traditional chocolate bar is a poor choice.

And not a diet drink, which is a genuinely common and consequential mistake.

2. Wait 10 to 15 minutes and recheck.

If they have a glucose meter, retest. If not, reassess how they seem.

3. If still low, repeat the fast-acting carbohydrate.

Up to three times. If it is not improving after that, call an ambulance.

4. Once they are above 4 and feeling better, give a longer-acting carbohydrate.

A sandwich, a couple of biscuits, a piece of fruit, a glass of milk, or their next meal if it is due.

This is the step people skip, and it is why hypos recur half an hour later. The fast sugar has been used up; the longer-acting food refills the tank.

Not needed if they are about to eat a meal, or if they are on an insulin pump.

5. Do not leave them alone, and let them rest.

If they are unconscious, drowsy, having a seizure, or unable to swallow safely:

Do not put anything in their mouth.

No food, no drink, no gel forced between the teeth. They will aspirate it.

Rubbing glucose gel into the inside of the cheek is sometimes taught and is only for someone who is conscious enough to swallow.

1. Recovery position.

2. Call an ambulance.

3. Give glucagon if it is available and you know how.

Glucagon is a hormone that tells the liver to release stored glucose (Chapter 12.5).

It comes as an injection kit or, increasingly, as a nasal powder that simply needs puffing into a nostril — which is far easier for a bystander.

It works within 10 to 15 minutes.

And two caveats worth knowing: it does not work well in someone whose liver glycogen is already depleted — after prolonged fasting, in alcohol-related hypoglycaemia, or after repeated hypos — and it commonly causes vomiting on waking, so keep them in the recovery position.

4. When they recover, give carbohydrate as above, because glucagon's effect is temporary.

5. They still need medical assessment, particularly after a sulfonylurea hypo, which can recur for many hours.

Hyperglycaemia — high blood glucose

Develops over hours to days, not minutes — which is why it is an urgent problem rather than an immediate one, and why the bystander response is to get help rather than to act.

Symptoms: excessive thirst, frequent urination, tiredness, blurred vision, weight loss, and dry skin and mouth.

Diabetic ketoacidosis

Mainly in type 1 diabetes, and it can be the first presentation (Chapter 18.7).

Without insulin, cells cannot take up glucose, so the body breaks down fat for fuel. That produces ketones, which are acids, and the blood becomes acidic.

Signs, which follow directly:

The general hyperglycaemia symptoms, plus:

Nausea, vomiting and abdominal pain — frequently severe enough to be mistaken for a surgical emergency.

Deep, rapid, sighing breathing — Kussmaul breathing — which is the body blowing off carbon dioxide to compensate for the acid.

A sweet, fruity smell on the breath, like pear drops or nail varnish remover — acetone.

Drowsiness, confusion, and eventually coma.

Dehydration, which is usually severe.

This is a medical emergency requiring intravenous fluids, insulin and potassium replacement in hospital.

And a modern trap worth knowing: euglycaemic DKA. In people taking SGLT2 inhibitors, ketoacidosis can occur with a glucose level that is normal or only mildly raised (Chapter 22.8). Which means the usual warning sign is absent, and the diagnosis depends on the symptoms and on checking ketones.

Sick day rules for anyone with type 1 diabetes — and these prevent a large share of admissions:

Never stop insulin, even if you are not eating. Illness raises insulin requirements.

Check glucose more often — every 2 to 4 hours.

Check ketones if glucose is above 14 or you feel unwell.

Drink plenty of fluid.

Take extra rapid-acting insulin according to your plan.

And seek help if you cannot keep fluids down, if ketones stay high, or if you are getting worse.

Hyperosmolar hyperglycaemic state

Mainly in older people with type 2 diabetes.

Extremely high glucose — frequently above 40 — with severe dehydration and confusion, and without significant ketones, because enough insulin is present to prevent ketone formation.

Develops over days, has a higher mortality than DKA, and carries a high risk of blood clots.

Emergency treatment with fluids and insulin.

What a bystander does for either: call an ambulance, keep them in the recovery position if drowsy, and give sips of water only if fully alert.

Seizures

Around 1 in 10 people will have a seizure at some point (Chapter 20.2).

Most seizures stop on their own within 1 to 3 minutes and need no treatment at all.

What is needed from a bystander is protection, timing and knowing when it has become an emergency.

During a tonic-clonic seizure

1. Note the time. This is the most important thing you do.

Duration determines whether it is an emergency, and people consistently overestimate how long a seizure lasted — a two-minute seizure feels like ten.

Look at a clock or start a timer.

2. Protect the head. Put something soft underneath — a folded jacket, a cushion, your hands.

3. Move dangerous objects away. Furniture, hot drinks, glass. Move the objects, not the person, unless they are somewhere genuinely dangerous like a road or water.

4. Loosen anything tight around the neck.

5. Do not restrain them. Holding limbs down causes fractures and dislocations and does not shorten the seizure.

6. Do not put anything in their mouth.

Not a spoon, not a wallet, not your fingers.

It is anatomically impossible to swallow your own tongue. The tongue can be bitten during a seizure and that heals. Forcing objects into the mouth breaks teeth, damages the jaw, causes choking, and gets rescuers' fingers bitten badly.

This piece of folk advice has caused far more injury than the thing it was meant to prevent.

7. When the jerking stops, roll them into the recovery position.

Breathing may be noisy or absent-looking during the seizure itself, and the person may go blue. That is expected and resolves once the seizure ends.

8. Stay with them until they are fully recovered.

The postictal phase — confusion, drowsiness, headache, sometimes agitation — can last minutes to hours.

Speak calmly, tell them where they are and what happened, and repeat it as many times as needed.

Do not give food or drink until fully alert.

And they may be embarrassed, may have been incontinent, and may be frightened. Clear bystanders away and preserve their dignity.

When to call an ambulance

The seizure lasts more than 5 minutes.

A second seizure follows without full recovery in between.

It is their first ever seizure.

They are injured.

They do not regain consciousness within about 15 minutes, or do not return to their normal self.

They have breathing difficulty afterwards.

It happened in water.

They are pregnant, or have diabetes.

Or you are worried for any reason.

And the corresponding point, which prevents unnecessary calls: a person known to have epilepsy who has their usual kind of seizure lasting under 5 minutes and recovers normally usually does not need an ambulance. Many people with epilepsy have several a month and do not want to spend those nights in an emergency department.

Status epilepticus

A seizure lasting over 5 minutes, or repeated seizures without recovery between them.

A medical emergency. Mortality rises with duration, and neuronal damage begins after around 30 minutes.

Treatment is a benzodiazepine — buccal midazolam squirted into the space between cheek and gum, or rectal diazepam.

Both can be given by trained family members at home, and having a rescue medication with a written plan prevents a large number of emergency admissions.

If you have been trained and the person has their medication, give it at 5 minutes and call an ambulance.

Focal seizures

The person may be conscious but confused, wandering, plucking at clothing, or making repetitive movements.

Do not restrain them. Guide them gently away from danger, speak calmly and quietly, and stay with them until they are fully aware.

They may not remember any of it.

Febrile convulsions

In children between 6 months and 5 years, during a fever (Chapter 13.4).

Frightening to watch and usually harmless.

Same management: protect, time it, recovery position afterwards.

Call an ambulance for a first one, if it lasts over 5 minutes, if the child does not recover properly, or if they seem seriously unwell.

They do not cause brain damage, and the increased risk of later epilepsy is small.

And do not put a feverish child in a cold bath or use tepid sponging — it is uncomfortable, causes shivering, and does not prevent further convulsions.

What is not a seizure

Fainting — a prodrome of feeling hot and nauseated with vision greying, pallor, rapid recovery, and often a trigger. Brief jerking occurs in a substantial proportion of faints, so jerking alone does not make it a seizure.

Cardiac arrest — a brief seizure at the moment of collapse is common in cardiac arrest. If they do not start breathing normally after the jerking stops, start CPR (Chapter 23.2). This is a genuinely important distinction and it is why breathing is checked after every seizure.

Non-epileptic attack disorder — a real and distressing condition, treated psychologically, and not deliberate (Chapter 20.2).

If you have diabetes or epilepsy

Carry identification — a bracelet, a card, or medical information on your phone's lock screen, which most phones support without unlocking.

Tell the people you spend time with what to do. A colleague who knows where your glucose tablets are is a genuine safety measure.

Keep hypo treatment with you at all times, and in the car.

Keep rescue medication accessible and make sure someone is trained in it.

Know your local driving rules and follow them, for both conditions.

And a specific point for anyone on insulin who drives: check glucose before driving and every two hours on a long journey, and keep fast-acting carbohydrate within reach rather than in the boot.

What the next page fixes

Chapter 23.12 covers calling for help — exactly what to say, what information matters, and how to be ready before anything happens.