This more serious hypoglycemic state is often characterized by ex treme tiredness and inability to communicate. You may be sitting and bangingyour hand on atable, walking aroundin adaze, or merely fail-
332 Treatment
ing to respond to questions.It's important that those who live or work with you learn that this is a fairly severe stage of hypoglycemia.
The likelihood that it's hypoglycemia is so great that valuable time may be wasted if treatment is delayed while someone fumbles about trying to measure your blood sugar.
It's quite possible that if you're given glu cose tablets you will not chew them, and may even spit them out.
The treatment at this stage is glucose gelby mouth.
Glucose prepared asa syrupy gel is sold in the United States under several brand names.At least one ofthese productsis not pure glucose (dextrose) but contains a mixture of long- and short-acting sugars, and therefore will not exertits full effectasrapidlyaswe'd like.At pres ent, I ask my patients to purchase a product called Glutose 15 (Pad dock Laboratories, Minneapolis, MN 55427; available from Rosedale Pharmacy).
Glutose 15 is packaged in a plastic tube (like toothpaste), with a twist-off cap.
Each tube contains 15 grams of glucose.
From Table 20-1 (page 325), we see that this amount will raise the blood sugar of a 140-pound person by 75 mg/dl (15 x 5).
An appropriate dose for most adults in this condition would be 1V4 tubes.
These would typically raise one'sblood sugar by about 110 mg/dl.
Some of the tubes of decorative icing used to write on birthday cakes contain almost pure glucose (dextrose), so you might save money by purchasing those.
Look in the baking section of most su permarkets, but make sure of the contents and weight.
To convert ounces to grams, multiply by 30.
Make sure that the major ingredient is glucose, as some brands aremosdy sucrose, which works too slowly.
We recommend that two tubes of Glutose 15,secured together with a rubber band, be placed at strategic locations about the house and place ofwork, aswellasin luggage when you travel with a companion.
It should not be refrigerated, asit may harden when cold.To adminis ter, someone should insert the tip of an open tube into the corner of your mouth, in between your lower gum and your cheek, and slowly squeeze out a small amount.
You will probably swallow this small amount.
After you swallow, a bit more of the gel should be gently squeezed from the tube.Within 5 minutes of ingesting, you should be able to answer questions.
When you have fully recovered, check and correct your blood sugar to your target.Sinceyou may havewiped the sticky geloff your mouth with your hands,you should washthem beforestickingyour finger.
Although glucose gels may not be available in many countries, they are available on the Internet.
Most industrialized nations have phar-
Howto Prevent and Correct LowBlood Sugars 333
macies and surgicaldealers that sellflavored glucose drinks to physi cians for performing oral glucose tolerance tests.
These are usually botded in 10-ounce(296ml) screw-top bottiesthat contain 100grams of glucose.
A dose of 2 fluid ounces (60 ml) will provide about 20 gramsof glucose, enough to raisethe blood sugarof a 140-pound per son by 100mg/dl.
Tiny amounts can be administeredwith the help of a plasticsqueeze bottle.
Whoever feeds you the liquid or gel must ex ercisecaution, as the possibilityexiststhat you could inhale some of it, causing you to choke.
The use of liquid is potentially much more haz ardous than the gel in this respect, so administer only a tiny amount for each swallow.
TREATING HYPOGLYCEMIA IF YOU ARE UNCONSCIOUS
Hypoglycemia is not the only cause of loss of consciousness.
Stroke, heart attack,a sudden drop in blood pressure, and evena bump on the headcan renderyou unconscious.
In fact, veryhighblood sugar(above 400mg/dl) overseveral days, especially in a dehydratedindividual,can also cause loss of consciousness.
We willassume, however, that if you are carefully observing the treatment guidelines of this book, you will not allow such prolongedblood sugarelevation to occur.
If you're found unconscious by someone who knows how to rapidly check your blood sugar, a measurement may be made.
Treatment should not be delayed, however, while people are scampering about trying to find your testing supplies.
The treatment under these conditions is injection of glucagon, a hormone that rapidlyraises bloodsugarbycausing the liver and mus cles to convert stored glycogen to glucose.
It is imperative, therefore, that those who live with you knowhowto give an injection.
If you use insulin,you can give them some practice by teaching them how to give you insulin injections.Glucagon is sold in pharmaciesin many coun tries as the Glucagon Emergency Kit.
This consists of a small plastic box containing a syringe filled with an inert waterlike solution and a litde vial of white powder (glucagon).
The kit also contains an illus trated instruction sheet that your family should read before an emer gency develops.
The user injects the water into the vial, withdraws the needle, shakes the vial to dissolve the powder in the water, and draws the solution back into the syringe.
The tip of the long needle must be
334 Treatment
submerged in the liquid.
For adults, the entire contents of the syringe should be injected, either intramuscularly or subcutaneously; lesser amounts should be used for small children.
Any of the sites shown in Figure 16-1 on page 251 can be used,as can the deltoid muscle (page 309) or even the calf muscle.
Your potential benefactors should be warned that if they choose the buttocks, injection should go into the upper outer quadrant, so as not to injure the sciatic nerve.An injec tion maybe given through clothingprovidedit isnot too thick (for ex ample, through a shirtsleeve or trouser leg, but not through a coat or jacket).
Under no circumstances should anything be administered by mouth whileyou are unconscious.
Since you willnot be able to swal low, oral glucose could asphyxiate you.
If your glucagon cannot be found, your companions should dial 911 (in the United States)for the emergency medicalservice, or you should be taken to the emergency room of a hospital.
When an individual has lost consciousness from hypoglycemia, he may experience convulsions.
Signs of this include salivation, tooth- grinding, and tongue-biting.
Although the last can cause permanent damage in the mouth, no attempt to intervene should be made.
Your heroic savior will not be able to help you if you bite off her fingers.
If possible, you should be turned to lie on your side with your head po sitioned so that your mouth is downward.This is to help drain excess salivafrom your mouth so you won't breathe it in and choke.
You should begin to show signs of recovery within 5 minutes of a glucagon injection.
You shouldfully regain consciousness and be able to talk sensibly within 20 minutes at most.
If steadyimprovement is not apparent during the first 10 minutes, the only recourse is the emergency squad or hospital.
The emergency squad should be asked to inject 40 cc of a 50 percent dextrose (glucose) solution into a vein.
Individualsweighing under 100pounds (45kilograms) should receive proportionately smaller amounts (e.g., a 70-pound child would re ceive 20 cc of the dextrose solution).
Glucagon can cause retching or vomiting in some people.
Your head should therefore be turned to the side so that if you do vomit, you won't inhale the vomitus.
Keep a 4-ounce (120 ml) bottie of metoclopramide syrup on hand, attached with a rubber band to the Glucagon Emergency Kit.
One gulp of metoclopramide, taken after you are sitting up and speaking, should almost immediately
How to Preventand Correct LowBloodSugars 335
stop the feeling of nausea.
Do not consume more than one gulp, as large doses can cause unpleasant side effects (see page 368).
In the United States, metoclopramide is available only upon prescription by a physician.
One doseof glucagon can raise your blood sugarby as much as 250 mg/dl, depending upon howmuchglycogen was storedin your liver at the time of the injection and subsequendy converted to glucose.
After you've fully recovered yoursenses, youshould check yourbloodsugar.
If at least 5 hours have elapsed since your last dose of a rapid-acting insulin, take enough intramuscular (or subcutaneous) lispro (or as part or glulisine) insulin to bringyourbloodsugar backdownto your target.
This is important, because if your blood sugar is kept normal for about 24hours,your liver will rebuild its supply of glycogen.
This glycogen reserve is of great value for protection from possible subse quent hypoglycemic events.
Bythe way, if we tried to give glucagon to someone twice in the same day, the second shotmight not raise blood sugar.
This ispossible because liver glycogen reserves may have been totally depleted in re sponseto the firstinjection.
Thus,monitoringand correctionof blood sugar every5 hours for 1 full dayis mandatoryafter the use of gluca gon.
Additional blood sugar measurements should be taken every 2l/z hoursto make surethat you're not again hypoglycemic, but do not correct for high blood sugars every 2l/i hours; wait the full 5 hours sincethe last shot of rapid-actinginsulin (see page305).
Although reading about possible loss of consciousness may be frightening, remember that thisisan extremely rareevent, and usually resultswhen a type 1diabeticmakes a major mistake, such as those in cluded in the list on pages 319-320.1 know of no case where a type 2 diabetic experienced severe hypoglycemia when using anymedication that we recommend.
HOW TO DETECT HYPOGLYCEMIA WHILE YOU ARE SLEEPING
Thesigns of hypoglycemia duringsleep include cold, clammy skin, es pecially on the neck, erratic breathing, and restlessness. It certainly helpsto havea lightsleeper sharingyourbed.Parentsshould checkdi abeticchildren at night and should feel their neck.
336 Treatment
KNOW WHY YOU WERE HYPOGLYCEMIC
Review your Glucograf data sheet after all hypoglycemic episodes, even mild ones.
It's important that you reconstruct the events leading up to any episode of low blood sugar, even if it caused no notable symptoms.
This is one of the reasons why we recommend (page 76) that most insulin-taking diabetics keep faithful records of data perti nent to their blood sugarlevels and whywewent into so much detail in Chapter 5 teaching you how to recordthe information.
Since severe hypoglycemia can lead to amnesia for events of the prior hour or so, habitual recording of relevantdata can be most valuablefor this sce nario.
It is certainly helpful to record times of insulin shots, glucose tablets, meals, and exercise, as wellas to note if you overate or under- ate, and so on.
Recording blood sugar data alone may not help you to figure out what caused a problem.
If you experience a severe hypo glycemic episode or several mild episodes and cannot figure out how to prevent recurrences, read or show your Glucograf data sheet to your physician.
Your doctor may be able to think of reasons that did not occur to you.
BE PREPARED
Keeping Hypoglycemia Supplies Glucose tablets, glucose gel (Glutose 15), and glucagon can each po tentiallysave your life. Theywon't help if they're not around or are al lowed to deteriorate. Here are some basic rules: