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Diabeties

mLpenguin

• 2 min read
Diabeties
Photo by Daniel Kraus / Unsplash

Diabetes in the ER: The Big Three Presentations

  1. Hyperglycemic Emergencies
    • Diabetic Ketoacidosis (DKA)
      • Common in type 1 but can occur in type 2.
      • Triad: Hyperglycemia, ketonemia/ketonuria, metabolic acidosis.
      • Presentation: Polyuria, polydipsia, abdominal pain, nausea/vomiting, Kussmaul respirations, fruity breath, AMS in severe cases.
    • Hyperosmolar Hyperglycemic State (HHS)
      • Typically in type 2.
      • Much higher glucose (often >600 mg/dL), minimal or no ketosis, severe dehydration, altered mental status.
      • Higher mortality than DKA (due to older age, comorbidities).
    • Mixed DKA/HHS can happen.
  2. Hypoglycemia
    • Defined as glucose <70 mg/dL, but symptoms often matter more than the number.
    • Causes: Excess insulin, sulfonylureas, missed meals, renal failure, sepsis.
    • Symptoms: Diaphoresis, tremor, palpitations → confusion, seizures, coma.
  3. Incidental Hyperglycemia
    • Very common - patient comes in for something else (e.g., cellulitis, chest pain) and glucose is elevated.
    • The question: Is this an emergency or outpatient issue?

Evaluation

When you see a diabetic patient, always think about:

  • ABC first (DKA patients may be sick).
  • Check bedside glucose immediately.
  • Labs to order if hyperglycemia is severe or symptomatic:
    • BMP (look at sodium correction, potassium, anion gap, bicarb).
    • VBG (pH, CO₂).
    • UA/serum ketones or β-hydroxybutyrate.
    • Serum osmolality (if suspect HHS).
    • CBC, cultures if infection suspected (often a trigger).
  • ECG: Hyper- or hypokalemia changes.

Management Principles

DKA/HHS

  • Fluids first – most patients are profoundly volume-depleted. Start with isotonic saline.
  • Electrolytes before insulin:
    • Correct potassium (hold insulin if K <3.3).
    • Monitor K frequently; insulin drives K into cells.
  • Insulin drip after fluids and adequate potassium.
  • Transition to subQ insulin when anion gap closes (DKA) or osmolality normalizes (HHS) and the patient is tolerating PO.
  • Identify the trigger (infection, missed insulin, MI, new-onset diabetes).

Hypoglycemia

  • If alert and able to swallow: give oral glucose (juice, tabs).
  • If altered: IV dextrose (D50) or IM glucagon if no IV access.
  • Admit if sulfonylurea-induced, recurrent, or unclear cause.

Incidental Hyperglycemia

  • If mild and asymptomatic: no emergent intervention.
  • If moderate-severe (esp. >300-350 mg/dL): consider labs to rule out DKA/HHS.
  • Disposition depends on symptoms, underlying cause, and follow-up reliability.

Pearls

  • Always check a glucose on altered mental status patients - hypoglycemia is a quick, reversible cause.
  • Don’t forget potassium - giving insulin without checking K can precipitate arrhythmia.
  • In DKA, the anion gap is your marker of resolution, not the glucose.
  • Never just “chase the number” - hyperglycemia alone isn’t an emergency unless there’s organ dysfunction.
  • Disposition is as important as acute management: Can this patient safely go home, or do they need admission for IV insulin and monitoring?
  • Life-threatening emergency (DKA/HHS, severe hypoglycemia) → resuscitate, admit.
  • Acute complication (infection, dehydration, medication error) → stabilize and treat the trigger.
  • Incidental finding → safe disposition, follow-up, and patient education.