Scenario: A 68-year-old man is found slumped over in a diner booth. He’s confused, slurring his words and can’t move his right arm. A bystander mentions he has diabetes. Is this a stroke? Or a diabetic emergency?
Both hypoglycemia and stroke can cause sudden neurological symptoms like confusion, weakness or slurred speech. However, their underlying causes and treatments differ drastically. Misdiagnosing one as the other can delay critical intervention or even worsen outcomes. Here’s how to tell them apart in the field.
🩸 Diagnosis A: Hypoglycemia (low blood sugar)
Hypoglycemia occurs when blood glucose levels drop below normal, depriving the brain of fuel. It can quickly mimic a stroke, especially in diabetics or patients on insulin.
Common hypoglycemia symptoms:
- Altered mental status: Patients may seem confused, agitated or disoriented as brain cells fail to get enough glucose.
- Sweating and pallor: Autonomic activation often triggers clammy skin, shakiness and anxiety.
- Slurred speech or weakness: Low blood sugar can affect neurological function, sometimes appearing stroke-like.
- Seizures or unconsciousness: In severe cases, the brain’s glucose deprivation can cause seizure activity or coma.
How patients can manage hypoglycemia symptoms:
- Consume quick-acting glucose: If awake and able, patients should ingest glucose tablets, juice or candy to rapidly raise sugar levels.
- Seek help if confused or seizing: A 911 call is essential if the patient cannot self-treat or is unconscious.
How hypoglycemia paitents present to EMS:
- Often found with a medical alert bracelet or insulin syringe nearby.
- May be unresponsive or unable to give a history.
- Vitals may show tachycardia and normal or low blood pressure.
EMS management of hypoglycemia:
- Check blood glucose immediately with glucometer.
- If BG < 60 mg/dL and patient is alert enough: give oral glucose.
- If unconscious or seizing: administer IV dextrose (D10 or D50) or IM glucagon if no IV access.
- Monitor for improvement and reassess neurological status post-glucose.
🧠 Diagnosis B: Stroke (cerebrovascular accident)
A stroke results from interrupted blood flow to part of the brain, either by clot (ischemic) or bleeding (hemorrhagic), leading to sudden neurological deficits.
Common stroke symptoms:
- Facial droop, arm weakness speech changes: The hallmark “FAST” signs point to a focal neurological event.
- Sudden onset: Symptoms usually appear abruptly and are often one-sided.
- Visual disturbances or loss of coordination: Depending on the brain region affected, balance and vision may be impaired.
- Headache and vomiting: More common in hemorrhagic strokes, often with high blood pressure.
How patients can manage stroke symptoms:
- Do NOT delay: Time is brain — call 911 immediately for any sudden neurological changes.
- Avoid eating or drinking: To reduce aspiration risk if altered.
How stroke patients present to EMS:
- Acute neurological symptoms like hemiparesis, aphasia or facial asymmetry.
- Often hypertensive or with irregular pulse (e.g., atrial fibrillation).
- May be awake but confused, or unresponsive in large strokes.
EMS management of stoke patients:
- Perform FAST/BEFAST assessment and document exact time of last known normal.
- Check glucose to rule out hypoglycemia.
- Rapid transport to stroke center; notify hospital early for stroke alert.
- Maintain oxygenation, avoid hypotension and manage airway if needed.
🔍 Hypoglycemia vs. stroke: Spot the differences
Both conditions can look similar — especially early on. A quick bedside glucose test is essential to distinguish them.
- Both can cause slurred speech and confusion. Hypoglycemia does this due to lack of brain fuel, while stroke causes it from brain tissue damage.
- Both may show focal weakness. Hypoglycemia can mimic unilateral weakness, but it’s typically reversible with glucose. Stroke-induced weakness usually persists.
- Hypoglycemia often presents with sweating and paleness. These autonomic symptoms are not typical in stroke.
- Stroke patients usually have asymmetric facial droop and limb deficits. These findings are less common in hypoglycemia and tend to resolve quickly after glucose correction.
- Blood glucose is normal or high in stroke, low in hypoglycemia: Always check before assuming neurological deficit equals stroke.
Assess wisely in the field
Both hypoglycemia and stroke can present with sudden confusion, slurred speech and weakness. Hypoglycemia can be rapidly reversed if recognized, while stroke demands urgent transport for clot-busting treatment. Glucose testing is the EMS provider’s most powerful diagnostic tool in these situations. Making the right call at the right time could be the difference between full recovery and permanent disability.
EMS1 is using generative AI to create some content that is edited and fact-checked by our editors.
