6 Diabetes Emergency Interventions

Stabilize and escalate

Diabetes-related emergencies can deteriorate quickly. Begin by assessing airway, breathing, circulation, level of consciousness, and immediate bedside glucose. Activate the emergency response for altered consciousness, seizure, severe breathing difficulty, shock, or suspected DKA or HHS. Do not delay stabilization while waiting for a complete history or laboratory results.

Reassess after each intervention. Repeat vital signs and mental-status checks, recheck glucose at the interval required by the protocol, and monitor intake, output, and cardiac rhythm when indicated. Escalate promptly if the person worsens or fails to respond. Follow local emergency protocols and authorized orders.

Recognize and treat hypoglycemia

A glucose reading below $70\ \text{mg/dL}$ is clinically important. Possible signs include sweating, tremor, hunger, palpitations, irritability, and confusion. Severe hypoglycemia is defined by the need for another person’s assistance, regardless of the measured glucose.

When the person is awake and can swallow safely, give fast-acting glucose or carbohydrate and recheck glucose after $15$ minutes. If it remains below $70\ \text{mg/dL}$, repeat treatment and reassess. After recovery, provide a snack or meal if appropriate and consider ongoing insulin or medication effects.

If the person is unconscious, seizing, or unable to swallow safely, give nothing by mouth. Call emergency services, administer prescribed glucagon if available, and provide emergency care according to protocol. Reassess consciousness and glucose. Because hypoglycemia may recur, urgent medical evaluation is needed. Do not give juice, food, or glucose gel when the person cannot swallow safely.

Recognize and respond to DKA

DKA results from insulin deficiency, which causes ketone production and metabolic acidosis. It can occur in type 1 or type 2 diabetes. Suspect DKA when nausea, vomiting, abdominal pain, dehydration, deep or labored breathing, or confusion occurs. A glucose reading that is not extremely high does not rule it out; DKA can occur with lower-than-expected glucose, including in people taking SGLT2 inhibitors. Assessment should include ketones and acid–base status, not glucose alone.

A disrupted insulin-pump cannula accompanied by vomiting, dehydration, or deep breathing is concerning for DKA. Pump interruption can rapidly produce insulin deficiency. Prioritize emergency hospital evaluation and communicate the pump interruption and symptoms. Do not delay escalation to troubleshoot the pump or try an unprescribed correction dose.

In DKA, insulin is essential, but it must be given using an authorized protocol with close glucose and electrolyte monitoring. Do not give an unsupervised extra dose as a substitute for emergency evaluation. A person with type 1 diabetes needs ongoing basal insulin; suspected DKA is not a reason to stop insulin without clinical direction. Glucose can improve before ketones and acidosis resolve, so continue treatment and monitoring according to the clinical protocol.

Recognize and respond to HHS

HHS is most often associated with type 2 diabetes. It involves profound hyperglycemia, dehydration, and increased blood osmolality, often with marked confusion or other neurologic changes; significant ketoacidosis is usually absent. In an older adult with type 2 diabetes, several days of poor fluid intake and frequent urination followed by weakness and new confusion are concerning for HHS, although other emergencies must also be considered. Do not assume HHS is harmless because the person has type 2 diabetes or does not report abdominal pain.

DKA and HHS are life-threatening emergencies requiring hospital care. Arrange urgent hospital-level evaluation, assess and support airway and circulation, establish monitoring, and promptly notify the responsible clinician or emergency team. Hospital evaluation may assess hyperosmolality, dehydration, electrolytes, ketones, acid–base status, and the underlying cause, as appropriate.

Coordinate hospital treatment safely

Hospital management of DKA or HHS generally includes IV fluids, insulin, electrolyte monitoring and replacement, frequent glucose checks, and evaluation and treatment of the precipitating cause, such as infection or missed insulin. Potassium must be assessed and managed before insulin is started or continued under the treatment protocol because insulin can lower serum potassium further.

A low potassium result before an insulin infusion is started requires immediate notification of the responsible clinician and protocol-directed potassium replacement and repeat testing. Insulin timing must be directed by the protocol; do not independently start or change an insulin infusion. Insulin can shift potassium into cells and worsen hypokalemia, increasing the risk of dangerous cardiac and muscle complications.

Older adults and people with heart failure or kidney disease may require more cautious fluid administration and frequent reassessment. Continue to monitor clinical condition and laboratory trends, and escalate if the person deteriorates or fails to improve.