Diabetic Emergencies: Hypoglycemia, DKA & HHS

• Check bedside glucose immediately (POC glucose)
• Assess ABCs and mental status; place on monitor, obtain IV access
• Draw labs: BMP, venous blood gas, ketones/β-hydroxybutyrate, serum osmolality if severe hyperglycemia

If patient can swallow

• Give rapid glucose: 15–20 g via juice or glucose gel
• Recheck in 15 minutes; repeat until ≥ 70 mg/dL (≥ 4.0 mmol/L)

Unable to take PO / severe symptoms

• IV dextrose (e.g., adult 25 g, pediatric weight-based)
• No IV? Give IM/IN glucagon
• Identify the cause; provide a complex carbohydrate once recovered

Core diagnostics

• DKA: hyperglycemia + anion-gap metabolic acidosis + positive ketones
• HHS: severe hyperglycemia, hyperosmolality, minimal/absent ketones
• Look for triggers: infection, MI, missed insulin, new-onset DM

Immediate actions

• Begin isotonic fluids promptly
• Check potassium before insulin; replace if low
• Start insulin infusion per protocol once K⁺ is safe

• Initial resuscitation: isotonic crystalloid bolus(es) for hypovolemia
• Ongoing: switch to balanced maintenance based on corrected sodium and osmolality
• Add dextrose (e.g., D5) to fluids as glucose approaches 200–250 mg/dL to continue anion gap closure

• Potassium repletion is essential; hold insulin if K⁺ is very low until replaced
• Consider phosphate only if symptomatic or markedly low
• Bicarbonate is rarely indicated; follow institutional guidance

• Typical infusion: weight-based continuous IV regular insulin (bolus optional per local policy)
• Goal: drop glucose gradually while closing the anion gap and clearing ketones

• When gap closes and patient can eat: transition to subcutaneous insulin with overlap
• Address precipitating cause (e.g., infection)

• Frequent checks: glucose, electrolytes, anion gap, venous pH/bicarbonate, fluid status
• Watch for cerebral edema (especially pediatrics) and careful osmolality shifts

• Before discharge: update sick-day rules, insulin access, and glucose monitoring
• Arrange diabetes follow-up and education