Emergency: If someone with Type 1 diabetes is unconscious, cannot be woken, is breathing rapidly and deeply, smells of acetone (sweet/fruity breath), or is confused and deteriorating — this is a medical emergency. Call for help immediately or go to the nearest emergency department. Emergency contacts are on the back of your medical aid card. View AURA emergency contacts →
The Two T1DM Emergencies You Need to Know
Type 1 diabetes has two life-threatening acute presentations: Diabetic Ketoacidosis (DKA) — too little insulin, glucose too high — and severe hypoglycaemia — too much insulin, glucose too low. They require opposite treatments. Knowing which one you're dealing with matters.
Scenario 1: Diabetic Ketoacidosis (DKA)
DKA occurs when there is insufficient insulin for the body to use glucose. Without insulin, the body switches to breaking down fat for fuel, producing ketones — acidic compounds that build up in the blood and become life-threatening.
Recognising DKA
DKA develops over hours, sometimes days. Symptoms escalate:
Early: Excessive thirst and urination, fatigue, blurred vision. Blood glucose typically above 14 mmol/L. Mild ketones on urine or finger-prick ketone strip.
Moderate: Nausea, vomiting, abdominal pain. Blood glucose high. Moderate ketones.
Severe: Rapid, deep breathing (Kussmaul breathing), sweet or fruity smell to the breath (acetone), confusion, drowsiness. High ketones. Blood pH dropping — this is life-threatening.
What triggers DKA?
- Missed insulin doses (most common cause)
- Undiagnosed T1DM at first presentation (20–80% of new T1DM diagnoses in sub-Saharan Africa present in DKA)
- Intercurrent illness (infection — illness raises blood glucose and insulin requirements dramatically)
- Insulin pump failure (if on CSII, the pump delivering a tiny amount of short-acting insulin continuously — any failure leads to rapid DKA)
What to do
If the patient is conscious and alert, with moderate symptoms: 1. Check blood glucose and ketones (if you have ketone strips) 2. Take a correction insulin dose as per your sick day management plan 3. Drink fluids 4. Contact your diabetes team or an endocrinologist immediately — do not manage DKA at home without medical guidance 5. If in doubt: go to hospital
If the patient is vomiting, confused, deeply breathing, or unconscious: Do not give insulin at home. Go to hospital immediately.
In hospital: IV fluids, IV insulin infusion, electrolyte replacement (particularly potassium), close monitoring, endocrinologist input. Usually 24–72 hours depending on severity.
The cost of a DKA admission
A DKA hospital admission in a private SA facility: approximately R25,000–R50,000. An ICU admission for severe DKA can reach R80,000–R150,000. The SAMJ published that a single preventable DKA admission costs approximately as much as 27 years of insulin therapy. Prevention is dramatically more cost-effective than management.
Scenario 2: Severe Hypoglycaemia (Dangerously Low Blood Sugar)
Hypoglycaemia occurs when blood glucose falls below 3.9 mmol/L. Most hypoglycaemic episodes are mild and self-treated. Severe hypoglycaemia — where the person cannot self-treat and requires external help — is the emergency.
Recognising hypoglycaemia
Mild/moderate (person can self-treat): Shakiness, sweating, hunger, palpitations, pallor, anxiety. Blood glucose below 3.9 mmol/L.
Severe (person cannot self-treat): Confusion, slurred speech, unusual behaviour, seizure, unconsciousness.
What to do
Conscious, can swallow: 1. Give fast-acting glucose immediately: 15g of carbohydrate — 150ml sweetened juice, 3–4 glucose tablets, or 3–4 teaspoons of sugar dissolved in water 2. Wait 15 minutes. Recheck blood glucose. 3. If below 3.9 mmol/L, repeat glucose. 4. Once blood glucose is above 4.0 mmol/L, give a carbohydrate snack.
Unconscious, cannot swallow: Do NOT give anything by mouth (aspiration risk). 1. If glucagon injection is available (prescribed by your doctor): administer as per instructions. 2. Lay the person on their side (recovery position). 3. Call for emergency help immediately. 4. The emergency team will give IV dextrose — this reverses hypoglycaemia rapidly.
The Gap Cover Picture for T1DM Emergencies
| Admission | Private hospital cost | Specialist shortfall risk |
|---|---|---|
| DKA, non-ICU (2–3 days) | R25,000–R50,000 | R5,000–R20,000 endocrinologist/internist shortfall |
| Severe DKA with ICU | R80,000–R150,000 | R15,000–R50,000 shortfall |
| Severe hypoglycaemia (emergency) | R12,000–R25,000 | R3,000–R10,000 shortfall |
Endocrinologists frequently bill above the medical scheme rate. Gap cover pays the difference between what the endocrinologist charges and what the scheme pays. Without it, a DKA admission can leave a family with R5,000–R50,000 in unplanned specialist costs in addition to the medical crisis.
What to Do If Already Admitted
- Call your scheme's pre-auth or emergency notification line as soon as possible — the number is on your card. For emergencies, notify within 24–48 hours.
- Note every specialist who attends — endocrinologist, emergency physician, intensivist if ICU. Each bills separately.
- Don't accept a verbal account. Request itemised accounts from each treating provider.
- Submit your gap cover claim once accounts are settled and scheme payment advice is received.
Preventing DKA: The Non-Negotiables
DKA is largely preventable. The evidence is clear on what prevents it:
1. Never miss insulin. Even during illness. In fact, illness INCREASES insulin requirements. Develop a sick day management plan with your diabetes team before you need it.
2. Use a CGM if possible. The FreeStyle Libre 2 alerts to rising blood glucose at night — when DKA risk is highest. It doesn't prevent DKA directly, but it gives you the information to act before the crisis develops.
3. Know your ketone strip routine. If blood glucose is above 14 mmol/L and not coming down, check ketones. Early ketone detection (moderate ketones before symptoms) allows intervention before DKA develops.
4. Have a glucagon kit in the house. For severe hypoglycaemia — ensure family members know how to use it. Your diabetes team or pharmacist can demonstrate.
Let's focus on what we can control: consistent insulin use, CGM where accessible, a written sick day plan, a glucagon kit at home, and a diabetes team that knows you. These things prevent the crisis.
Check your scheme's cover for T1DM emergencies →
If someone with T1DM is unconscious or critically unwell right now: stop reading and call for emergency help. Emergency contacts are on the back of your medical aid card. View AURA emergency contacts →