Diabetic Emergencies: First Aid for Hypoglycemia, DKA, and HHS (2026)

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World Diabetes Day and Diabetic Emergencies: Why First Aid Matters

Every year on November 14th, the global community observes World Diabetes Day to raise awareness about one of the fastest-growing health conditions in the world. In Canada alone, more than 3.7 million people are living with diabetes, and that number continues to rise every year. While diabetes is primarily managed through lifestyle modifications and medical treatment, the condition can produce life-threatening emergencies that require immediate attention. Diabetic emergencies are critical situations in diabetes management that require immediate attention because they can be life-threatening.

World Diabetes Day was established in 1991 by the International Diabetes Federation and the World Health Organization. November 14th was chosen because it marks the birthday of Sir Frederick Banting, the Canadian physician who co-discovered insulin in 1921 at the University of Toronto. That breakthrough has saved millions of lives and remains one of Canada’s greatest contributions to global health.

The three primary diabetic emergencies are hypoglycemia (low blood sugar), diabetic ketoacidosis (DKA), and hyperosmolar hyperglycemic state (HHS). The two most common diabetic emergencies are diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS), with severe hypoglycemia also being a key concern. Each requires a different first aid response, and each can be fatal without prompt action.

Types of Diabetes: What You Need to Know

Type 1 Diabetes

Type 1 diabetes is an autoimmune condition in which the body’s immune system attacks and destroys the insulin-producing cells in the pancreas. Without insulin, the body cannot move glucose from the bloodstream into cells for energy. People with Type 1 diabetes must take insulin every day to survive. DKA is most common in type 1 diabetes because the absolute shortage of insulin causes the body to produce ketones as an alternative fuel source. This type accounts for approximately 5 to 10 percent of all diabetes cases and is most commonly diagnosed in children and young adults.

Type 2 Diabetes

Type 2 diabetes is the most common form, accounting for about 90 percent of all cases. It develops when the body becomes resistant to insulin or when the pancreas gradually loses its ability to produce enough insulin. HHS is more often seen in people living with type 2 diabetes, although either condition can affect anyone with diabetes. Risk factors include family history, obesity, physical inactivity, age, and ethnicity. Regular monitoring of blood glucose levels is essential for people with diabetes, especially during periods of illness, to prevent fluctuations that can lead to emergencies.

Gestational Diabetes

Gestational diabetes develops during pregnancy and typically resolves after birth. However, women who have had gestational diabetes have a significantly higher risk of developing Type 2 diabetes later in life. Monitoring blood glucose carefully during pregnancy is essential for the health of both mother and baby, and gestational diabetes is considered a risk factor for future hyperglycemic emergencies.

The Three Primary Diabetic Emergencies

What Is Hypoglycemia: Low Blood Sugar and Its Risks?

Hypoglycemia occurs when blood glucose drops below normal levels, which can starve the brain of fuel. In clinical terms, hypoglycemia is defined as blood glucose falling below 4.0 mmol/L. This is the more common and more immediately dangerous diabetic emergency in day-to-day life. It can develop rapidly within minutes and can quickly progress to unconsciousness and seizures if not treated.

Causes of hypoglycemia include taking too much insulin, skipping meals, excessive physical activity, and alcohol consumption. Certain drugs affecting blood glucose control, including medications used for infection or other conditions, can also trigger hypoglycemic episodes. People with hypoglycemia unawareness are at particular risk because they do not experience the usual warning signs before their blood glucose drops to a dangerous level, making bystander recognition even more critical.

Early signs of hypoglycemia include: shakiness and trembling, sweating and pale clammy skin, rapid heartbeat and extreme hunger, dizziness and lightheadedness, confusion and difficulty concentrating, irritability or sudden mood changes, and blurred vision and weakness.

Severe Hypoglycemia: When Low Blood Sugar Becomes Life-Threatening

Severe hypoglycemia can result in seizures, loss of consciousness, or coma. In Ontario, in-hospital mortality in people hospitalized for acute hyperglycemia ranged from under 1 percent at ages 20 to 49 years to 16 percent in those over 75 years, underscoring the importance of early intervention. Severe hypoglycemia requires immediate attention and emergency services if the person is unconscious, having seizures, or unable to swallow safely. The incidence of severe hypoglycemic events increases significantly in older adults and in patients with long-standing diabetes who have developed hypoglycemia unawareness.

What Is Diabetic Ketoacidosis (DKA)?

DKA is a metabolic crisis caused by an absolute shortage of insulin, leading the body to produce ketones as an alternative fuel source. When insulin is absent, the body breaks down fat, producing ketones that acidify the blood. This process is called ketosis and, when severe, progresses to ketoacidosis. DKA is most common in people with type 1 diabetes but can affect anyone with diabetes who has severely uncontrolled blood glucose. Severe diabetic ketoacidosis is a life-threatening hyperglycemic crisis requiring emergency room treatment without delay.

In DKA, blood glucose levels are usually 14.0 mmol/L or above. Symptoms of diabetic ketoacidosis (DKA) include nausea, vomiting, abdominal pain, and a feeling of being unable to get enough oxygen, collectively referred to as acidosis. Common signs of DKA also include shortness of breath, fruity breath odor, and severe abdominal pain. Common triggers for DKA beyond missed insulin include infection, illness, cardiac surgery, and myocardial infarction, all of which dramatically increase the body’s insulin requirements. People recovering from surgery or a cardiac event should monitor blood glucose closely for signs of hyperglycemic crises.

• Excessive thirst and frequent urination
• Nausea, vomiting, and severe abdominal pain
• Fruity breath odor from ketones in the urine and breath
• Deep and rapid breathing (Kussmaul breathing)
• Confusion and drowsiness
• Eventual loss of consciousness and coma

What Is Hyperosmolar Hyperglycemic Syndrome (HHS)?

Hyperosmolar hyperglycemic syndrome (HHS), also called hyperosmolar hyperglycemic state, hyperglycemic hyperosmolar state, or hyperosmolar nonketotic coma, is a hyperglycemic emergency that typically affects older adults with type 2 diabetes. Hyperglycemia usually develops slowly and can lead to severe dehydration and life-threatening conditions like DKA or HHS if untreated. Medications including diuretics and glucocorticoids can trigger or worsen HHS by promoting dehydration and raising blood glucose levels.

In DKA, blood glucose levels are usually 14.0 mmol/L or above, while in HHS they can be significantly higher, typically 34.0 mmol/L or above, along with plasma osmolality above 320 mOsm/kg. HHS typically presents with neurological signs such as vision problems or delirium, along with increased urination and dehydration. Signs of dehydration in HHS include extreme thirst, dry mouth, sunken eyes, and rapid pulse. HHS is a critical medical emergency requiring intensive care treatment and massive fluid rehydration as a priority. Mortality is significantly higher in HHS than in DKA, particularly in older adults and patients with pre-existing conditions.

DKA vs HHS: Key Differences at a Glance

Understanding the difference between DKA and HHS helps you communicate more clearly with emergency dispatchers and medical professionals when someone experiences a hyperglycemic crisis.

First Aid for Diabetic Emergencies: Step by Step

In a diabetic emergency, assessing the person’s level of consciousness and their ability to swallow safely is the most critical first step. Never give anything by mouth to someone who is unconscious or unable to swallow, as this creates a serious aspiration risk. Intermediate / Standard First Aid with CPR C covers diabetic emergency response, the Rule of 15, and glucagon administration as part of the core curriculum.

The Rule of 15: First Aid for Low Blood Sugar

If blood sugar levels cannot be determined, standard protocols suggest treating as if the person has hypoglycemia. This is the safer approach because treating a high blood sugar with a small amount of sugar causes minimal harm, while failing to treat dangerously low blood sugar can be fatal.

For a conscious person who can swallow safely, follow the Rule of 15:

• Step 1: Give 15 grams of fast-acting sugar immediately. Options include 4 glucose tablets, half a cup (125 mL) of fruit juice or regular soft drink, 1 tablespoon of honey or sugar, or 6 to 7 hard candies.
• Step 2: Wait 15 minutes and reassess symptoms.
• Step 3: If symptoms have not improved, repeat the 15-gram dose of fast-acting sugar.
• Step 4: Once symptoms improve, give a more substantial snack containing both carbohydrates and protein to stabilize blood glucose levels and prevent a rebound drop.

If the person is unconscious or unable to swallow safely, do not give anything by mouth. Call 911 immediately. Place the person in the recovery position on their side to protect their airway. If the person carries a glucagon kit and you are trained to use it, administer glucagon as directed. The glucagon kit works by signaling the liver to release stored glucose into the bloodstream, raising blood glucose without requiring oral intake. Stay with the person and monitor their breathing and level of consciousness until emergency services arrive.

First Aid for Hyperglycemic Emergencies: DKA and HHS

Hyperglycemia that has progressed to DKA or HHS requires emergency room treatment and cannot be managed with first aid alone. Management of diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) includes restoring normal extracellular fluid volume and correcting electrolyte imbalances. Fluid therapy is essential in managing DKA, with initial intravenous normal saline administration recommended at a rate of 500 mL/h for the first four hours, followed by adjustments based on the patient’s condition.

As a bystander, your role is to call 911 immediately if the person is vomiting, has fruity-smelling breath, is breathing abnormally, or is showing signs of altered consciousness. Keep the person comfortable and calm. Place them in the recovery position if unconscious but breathing. Monitor their airway and breathing continuously. Do not give food or drink if they are vomiting or their level of consciousness is reduced. Tell paramedics what you observed, including any known diabetes diagnosis, medications, and the time symptoms began.

Hypoglycemia Unawareness: A Hidden Risk

Hypoglycemia unawareness is a condition in which a person with diabetes no longer experiences the early warning signs of low blood glucose. Over time, the body’s hormonal response to falling blood glucose becomes blunted, particularly in people who have had diabetes for many years or who have experienced frequent hypoglycemic episodes. Blood glucose can drop to dangerous levels without the person feeling any symptoms.

For bystanders and coworkers, hypoglycemia unawareness means that someone with diabetes may appear suddenly confused, unresponsive, or unconscious without warning. This makes it especially important for people around those with diabetes to know the signs of a diabetic emergency, even when the person themselves cannot signal that something is wrong. If someone with known diabetes suddenly appears confused, pale, or unresponsive, treat for hypoglycemia immediately and call 911.

The Glucagon Kit: What It Is and How It Helps

A glucagon kit is an emergency treatment for severe hypoglycemia when the person is unconscious or unable to swallow. Glucagon is a hormone that signals the liver to release stored glucose into the bloodstream. Many people with type 1 diabetes and some with type 2 diabetes carry a glucagon kit as part of their emergency preparedness.

Glucagon kits come in two forms: an injectable kit that requires reconstitution before use, and a nasal spray form that is simpler to administer. If someone collapses from a diabetic emergency and you locate a glucagon kit, call 911 first, then follow the step-by-step instructions on the kit. The correct dose is included in the kit instructions. Most modern glucagon kits are designed to be used by untrained bystanders with clear instructions. After administering glucagon, the person should begin to recover within 10 to 15 minutes. Even if they recover, paramedics should still assess them because blood glucose may drop again without follow-up treatment.

Sick-Day Plan: Preventing Diabetic Emergencies Before They Start

Preventing diabetic emergencies starts with proactive care, including creating a sick-day plan with healthcare providers to manage medications during illness. Illness and infection are among the most common triggers for both DKA and HHS, because physical stress causes blood glucose levels to rise even if the person is not eating. Sick-day management that includes capillary beta-hydroxybutyrate monitoring reduces emergency room visits and hospitalizations in young people with type 1 diabetes.

A comprehensive sick-day plan typically includes instructions for adjusting insulin or oral medication doses during illness, guidance on how frequently to check blood glucose when sick, rules for when to check for ketones in urine or blood, a threshold for when to call a healthcare provider or go to the emergency room, a list of safe foods and fluids to consume when unable to eat normally, and instructions for managing diuretics, glucocorticoids, and other drugs that affect blood glucose during illness. Regular monitoring of blood glucose levels is essential for people with diabetes, especially during periods when ill, to prevent fluctuations that lead to emergencies.

Diabetes in the Workplace

With 3.7 million Canadians living with diabetes, virtually every workplace has employees managing the condition. Employers have both a legal and ethical responsibility to ensure workplaces are safe and supportive for employees with diabetes. This includes allowing employees to monitor their blood sugar and take medications as needed, providing access to food and beverages for managing blood glucose, training designated first aiders to recognize and respond to diabetic emergencies, and including diabetes management in workplace emergency plans.

Investing in workplace first aid training that covers diabetic emergencies ensures that coworkers can respond effectively when someone experiences a blood sugar crisis. For workplaces with higher risk, private group first aid training can be customized to include specific diabetic emergency protocols. This training aligns with CSA Z1210:24 workplace first aid standards.

Diabetes Prevention: Reducing Your Risk

While type 1 diabetes cannot currently be prevented, the risk of developing type 2 diabetes can be significantly reduced through lifestyle modifications. Maintaining a healthy weight, engaging in at least 150 minutes of moderate physical activity per week, eating a balanced diet, limiting consumption of processed foods and sugary drinks, and getting regular health screenings are all proven strategies. The American Diabetes Association recommends a combination of aerobic exercise and resistance training for optimal glycemic control.

Physical activities like swimming are particularly beneficial for diabetes prevention and management because they provide excellent cardiovascular exercise while being gentle on the joints. Regular physical activity improves insulin sensitivity, helps maintain a healthy weight, and reduces stress, all of which contribute to better blood sugar control and overall health.

This World Diabetes Day: Take Action

This World Diabetes Day, consider taking action by learning the signs and symptoms of diabetic emergencies, talking to friends and family members with diabetes about their emergency action plans, ensuring your workplace has trained first aiders, and enrolling in a first aid course that covers medical emergencies including diabetes.

Basic Emergency First Aid covers the fundamentals of recognizing and responding to blood glucose crises. Intermediate / Standard First Aid courses go deeper, covering the Rule of 15, glucagon administration, recognition of DKA and HHS, and when to call 911. Hands-on training builds the confidence and competence to act correctly under pressure when every minute matters.

Frequently Asked Questions: 2026 Diabetic Emergencies First Aid

More FAQs: DKA, Sick-Day Plans, and Workplace Safety