3 Diabetic Emergencies

Recognize diabetic emergencies

Diabetic emergencies require rapid recognition and coordinated treatment. Nursing priorities include assessing airway, breathing, circulation, mental status, and vital signs; checking point-of-care glucose; initiating prescribed treatment promptly; and closely monitoring the patient’s response.

Hypoglycemia is an acute low-glucose emergency. Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) are life-threatening hyperglycemic crises. Suspected DKA or HHS requires urgent medical evaluation.

Identify and treat hypoglycemia

In most people, Hypoglycemia is a blood glucose level below $70\text{ mg/dL }(3.9\text{ mmol/L})$. Possible causes include too much insulin or glucose-lowering medication, delayed or missed food, unexpected activity, or illness. Symptoms can develop quickly, and some people have reduced awareness of warning symptoms.

Early signs include shakiness, sweating, palpitations, hunger, anxiety, and pallor. As hypoglycemia worsens, it may cause confusion, weakness, impaired coordination, seizures, or loss of consciousness.

Respond according to swallowing safety

1. Check glucose promptly if doing so does not delay treatment. If symptoms strongly suggest hypoglycemia and testing is not immediately available, treat the suspected low and check glucose as soon as possible.

2. If the patient is alert and can swallow safely, give $15\text{ g}$ of fast-acting carbohydrate, such as glucose tablets or $4\text{ oz }(120\text{ mL})$ of juice or regular soda. Recheck glucose after $15\text{ minutes}$; repeat treatment if glucose remains below $70\text{ mg/dL}$. Once glucose has recovered, provide a carbohydrate-and-protein snack if the next meal is not soon.

3. If the patient is unconscious, having a seizure, or unable to swallow safely, give nothing by mouth. Call for emergency assistance and administer prescribed glucagon or IV dextrose according to the care setting’s protocol. Protect the patient from injury, position them to help protect the airway, and reassess glucose and level of consciousness.

After recovery, investigate possible causes, including medication timing, food intake, or activity. Report recurrent or severe episodes for review of the treatment plan.

Distinguish DKA from HHS

Diabetic ketoacidosis (DKA) occurs when inadequate insulin leads to fat breakdown, ketone production, and metabolic acidosis. It can develop rapidly and occurs most often in people with type 1 diabetes, but it can also occur in people with type 2 diabetes.

Hyperosmolar hyperglycemic state (HHS) typically involves profound hyperglycemia, dehydration, and increased serum osmolality, with little or no significant ketosis or acidosis. It often develops over days and is more common in older adults with type 2 diabetes. A person may have features of both conditions.

Compare presentation and diagnostic patterns

• Typical DKA presentation: Often rapid onset, with nausea, vomiting, abdominal pain, deep or rapid breathing, and sometimes a fruity breath odor.

• Typical HHS presentation: Often gradual onset, with marked thirst, urination, dehydration, weakness, and altered mental status or seizures.

• Adult DKA laboratory pattern: Glucose $\geq 200\text{ mg/dL}$ or known diabetes, significant ketones, and acidosis, defined as pH $<7.3$ and/or bicarbonate $<18\text{ mmol/L}$.

• Adult HHS laboratory pattern: Glucose $\geq 600\text{ mg/dL}$ and hyperosmolality, defined as effective osmolality $>300\text{ mOsm/kg}$ or total osmolality $>320\text{ mOsm/kg}$, without substantial ketonemia or acidosis.

These diagnostic criteria are assessed together; a single glucose result does not establish or exclude a crisis. DKA can occur with glucose below the usual high levels, including in some people taking SGLT2 inhibitors. Common triggers for DKA or HHS include infection, missed insulin, other acute illness, and medication-related factors.

The major immediate concerns in DKA are acidosis, dehydration, and electrolyte shifts. In HHS, the major concerns are severe dehydration and hyperosmolality, often accompanied by neurologic impairment.

Assess and begin crisis treatment

Treat suspected DKA or HHS as an emergency. Assess airway, breathing, circulation, vital signs, hydration, urine output, and mental status. Notify the appropriate clinician or activate the emergency response according to the setting. Obtain point-of-care glucose and facilitate ordered tests, commonly including electrolytes, renal function, ketones, venous pH, and serum osmolality. Monitor cardiac rhythm when indicated, especially when potassium is abnormal.

Treatment generally involves IV fluids, insulin, electrolyte management, and treatment of the precipitating cause.

Fluids and insulin

For adults without cardiac or renal compromise, consensus guidance describes initial isotonic saline or balanced crystalloid at $500\text{–}1{,}000\text{ mL/hour}$ for the first $2\text{–}4\text{ hours}$. The rate and subsequent fluids must be individualized. Older adults and people with heart or kidney disease may need more cautious fluid replacement.

IV insulin is commonly used for significant DKA and HHS under a prescribed protocol. Do not give insulin without checking potassium and following the protocol. If potassium is below $3.5\text{ mmol/L}$, insulin is generally delayed while potassium is replaced, because insulin can lower serum potassium further and cause dangerous arrhythmias or muscle weakness.

During DKA treatment, glucose may fall before acidosis and ketones have resolved. When glucose falls below $250\text{ mg/dL}$, prescribed fluids are generally adjusted to include dextrose so insulin can continue safely until ketoacidosis resolves. HHS also requires careful, monitored correction of dehydration and hyperosmolality; avoid rapid or unprescribed changes in fluids or insulin.

Monitor treatment and prevent recurrence

Follow the ordered protocol and document trends in glucose, electrolytes—particularly potassium—fluid intake and output, vital signs, neurologic status, and response to treatment. Adult consensus guidance recommends bedside glucose checks every $1\text{–}2\text{ hours}$ during crisis treatment. Repeat laboratory tests at the intervals specified by the treatment protocol.

Watch for treatment complications, including hypoglycemia, hypokalemia, fluid overload, and worsening neurologic status. Identify and help treat the underlying trigger, such as infection, as ordered.

Before stopping an IV insulin infusion, ensure a prescribed subcutaneous insulin plan is in place. Basal insulin is generally given before the infusion is stopped, with overlap determined by the treatment protocol, to reduce the risk of recurrent hyperglycemia or ketoacidosis.

Reinforce individualized sick-day guidance, medication adherence, glucose and ketone monitoring, hydration, and when to seek urgent care.