Although everyone has high and low blood sugars on occasion, some levels can be dangerous when you live with diabetes. Here are some of the common scenarios people with diabetes and their caregivers should know about.
Severe hypoglycemia (low blood sugar)
Most lows are easily treated by the person with diabetes, but depending on the circumstances, assistance may be required. This could be as simple as having someone get fast acting glucose for you or as intensive as giving glucagon. A severe hypo is defined as one where the person requires assistance due to either mental or physical challenges related to a low glucose level.1
These physical or mental challenges could include the following:
- Confusion
- Lethargy
- Blurred vision
- Irritability
- Shaking or trembling
- Difficulty walking
- Syncope (losing consciousness)
- Seizures
Buccal (cheek) absorption of glucose
If the person cannot actively consume fast acting glucose, treating a severe low with glucose that can be absorbed in the cheek should be the first step. If the person with the low is suffering from an altered level of consciousness, make sure that this glucose is something that is thick enough to prevent the person from choking. A few good options are glucose gels, honey or cake icing.
Glucagon
Glucagon is another hormone made in the pancreas, and it tells the liver to empty the stored glucose (glycogen) into the bloodstream to raise the blood sugar. When someone with diabetes has a severe hypoglycemic episode, the first line of treatment after trying to get glucose ingested is glucagon. Glucagon comes in two different forms in 2025: nasal and injectable. Learn more about glucagon options for people with diabetes here. CWD’s Chief Operating Officer, Leigh Fickling, wrote an insightful article about giving her daughter glucagon, which is also a great resource.
Tips for glucagon use:
- If you are giving glucagon to someone who is unconscious, roll them onto their side in case they vomit, which can happen, and be sure to call for emergency help.
- Try to get the person, or yourself, to eat a snack after the glucagon is administered to help keep the blood sugar up once it’s brought back to normal.
- If you have not noticed a rise in the blood glucose 15 minutes after glucagon is taken, you can give another dose, if you have it.
- Anyone who takes insulin should have a prescription for glucagon and carry it while traveling, exercising, and whenever else you can.
- Glucagon should be kept in an easily identified and accessible location.
- Caregivers or family members should know where it is and how to administer.
- Glucagon may not work as effectively if you have been drinking alcohol or do not have enough glycogen stores in your liver.
- For example: if you have recently run a marathon and have not eaten very much, you may have used up your glycogen stores.
- It also may be less effective if it is expired
If you are starting to go low and experiencing nausea or vomiting, or are worried you may need glucagon, you can always give it or consider trying mini-dose glucagon. To use mini dose, you will need one of the traditional/older glucagon’s that come in the red or orange kits. This is less likely to cause the side effects that are common with a full dose of glucagon.
Ketones and ketoacidosis
Ketones are a biproduct of the body burning fat for energy, and for people without diabetes, this is not a problem because their body will level out the ketones. But when your body does not make insulin, ketones can build up and make your blood too acidic – this is called ketoacidosis. Low levels of ketones are not an emergency, but monitoring until they resolve is important as ketoacidosis can lead be deadly. Always remember to check your/your loved one’s ketone levels during time of illness, especially for a gastric illness.
The most common symptoms for elevated ketones and ketoacidosis are:
- Nausea or vomiting
- Persistent high blood glucose levels*
- Fruity smelling breath
- Abdominal pain
- Lethargy or fatigue
- Confusion
- Short, rapid breathing
- Deep, labored, and gasping breathing (known as Kussmaul breathing)
*Glucose levels can be in target range and ketones may still be present, especially if the person is taking other medications such as SGLT2 Inhibitors or GLP1 Agonists
Ketone management2
The key to treating or managing ketones is a combination of hydration and adequate insulin. Depending on how high your ketones are, you may have to add more insulin than usual to treat the ketones. Here are some tips for the various levels of ketones.
| Ketone Level | Actions |
| Trace/Small Ketones (0 – 0.9 mmol/L) | – You’re not in the danger zone but monitor closely.
– Refresh insulin (new pen or pump cartridge, tubing, infusion set). – Hydrate: * Fluids with sugar if BG < 90 mg/dL (<5 mmol/L). * Sugar-free fluids if BG is higher. – Consider eating extra carbs and bolusing normally to avoid starvation ketones. – Consider reducing total daily insulin if BG is running < 90 mg/dL (<5 mmol/L). |
| Small/Moderate Ketones (1-1.4 mmol/L) | – Refresh insulin (new pen or pump cartridge, tubing, infusion set).
– Hydrate with fluids containing sugar (bolus for them). – Bolus for foods consumed, even if BG is low or normal. – Give corrections if BG > 90-100 mg/dL (5-6 mmol/L). |
| Moderate/Large Ketones (1.5 – 2.9 mmol/L) | – Do not reduce total daily insulin.
– Refresh insulin (new pen or pump cartridge, tubing, infusion set). – Hydrate with fluids containing sugar (bolus for them) and add 5% of Total Daily Dose (TDD) to the bolus. – Bolus for foods consumed, even if BG is low or normal. – Give corrections if BG > 90-100 mg/dL (5-6 mmol/L). – Watch for signs of DKA: nausea, vomiting, changes in consciousness, short/rapid breathing, fruity breath (if present, go to ER). |
| Large Ketones (>3 mmol/L) | – Contact your diabetes team and consider going to the ER.
– If nausea/vomiting, drowsy, or breathing rapidly, go to ER immediately or call 911. |
Calculating Total Daily Dose
To calculate the total daily insulin dose, you will add up all the insulin given in a typical day. This includes both basal and bolus insulin – so the long-acting nighttime/morning dose and all the doses you take throughout the day. Insulin pumps will have the Total Daily Dose in the history menu, typically.
Other possible emergencies
There are some other less common challenges that can lead to emergencies as well. Here are some unfortunately common examples –
- Inadvertently taking the wrong type or wrong dose of insulin, leading to an excess of insulin on board and the need to go get an intravenous (IV) infusion of dextrose (sugar).
- Inability to bring down elevated glucose levels without ketones present
- Running out of medication, especially insulin, or supplies
- Becoming severely ill and needing assistance regardless of glucose levels
Preparing for these possibilities is the best way to keep yourself or your loved one safe. Make sure you have a plan for managing diabetes in these situations and know who to call or where to go if you need assistance. When in doubt, call your healthcare team or seek urgent or emergent assistance, depending on the severity of your circumstance. Hopefully, you’ll be as prepared as you can be, and luck favors the prepared.
- Management of Individuals With Diabetes at High Risk for Hypoglycemia: An Endocrine Society Clinical Practice Guideline
- Sick Day Guidelines 2023
Written and clinically reviewed by Marissa Town, RN, BSN, CDCES
