Emergency

Diabetes
SEPTIAN MIXROVA SEBAYANG
Objective

▪ Identify the diabetic complication in emergency setting

▪ Describe diabetic ketoacidosis, hyperosmolar syndrome,
and hypoglycemia
▪ Describe their emergency treatment
 Introduction

▪The incidence of diabetes mellitus (DM), a common chronic non-

communicable disease, is on the rise in many countries around the world
1
.
▪Due to the high prevalence of DM, emergency admissions for
hyperglycemic crisis, diabetic ketoacidosis (DKA) and hyperglycemic
hyperosmolar state (HHS) are fairly common and represent very
challenging clinical management in practice.
▪High-quality evidence for the management of hypoglycaemia was lacking,
limiting treatment recommendations.

1. Kaiser, A. B., Zhang, N. & Van Der Pluijm, W. Global prevalence of type 2 diabetes over the next ten years (2018–2028). Diabetes67(1),
202 (2018)
 Number and rate of emergency department visits per
1,000 adults aged 18 years or older with diabetes

ED Number Crude rate per 1,000 (95% CI)

Diabetic ketoacidosis 223,000 8.9 (8.2–9.5)

Hyperosmolar hyperglycemic
25,000 1.0 (0.9–1.1)
syndrome

Hypoglycemia 242,000 9.6 (8.9–10.3)

Data sources: 2018 National Emergency Department Sample; 2018 National Health Interview Survey.
https://www.cdc.gov/diabetes/data/statistics-report/coexisting-conditions-complications.html
 Classification Diabetes Emergencies

Hyperglycemic Emergency Hypoglycemic

Emergency
Diabetic ketoacidosis (DKA)

Hyperglycemic hyperosmolar Hypoglycemic

state (HHS)

https://doi.org/10.2337/db22-1028-P
Diabetic Ketoasidosis
 Definitions
Cause of Death in Adults: Hypokalemic
Cardiac Arrest (rare)
▪ Blood glucose >250 mg/dl
▪ Metabolic acidosis with ph <7.3 or serum bicarbonate <15mM
▪ “MILD DKA” is Bicarb 15-18
▪ “MODERATE DKA” is Bicarb 15 or above with ph >7.0
▪ “SEVERE DKA” is Bicarb <15 with ph 7.0 or below
▪ “EARLY DKA” is any Bicarb deficit in the setting of insulin deficiency, a
non-official term
▪ Ketonemia
▪ note: most patients with ketonemia have + urine ketones, or ketonuria
Diagnostic criteria

▪ :all three of the following must be present

▪ capillary blood glucose above 11 mmol/L
▪ capillary ketones above 3 mmol/L or urine ketones ++ or
more
▪ venous pH less than 7.3 and/or bicarbonate less than 15
mmol/L
 Emergency care of DKA

▪ Immediate management: time 0 to 60 minutes

▪ 60 minutes to 6 hours
▪ 6 to 12 hours
▪ 12 to 24 HOURS

http://www.bsped.org.uk/professional/guidelines/docs/DKAGuideline.pdf
 Emergency care of DKA

▪ Immediate management: time 0 to 60 minutes

▪ Commence 0.9% sodium chloride solution (use large bore cannula) via
infusion pump.
▪ Commence a fixed rate intravenous insulin infusion (IVII).
Assess patient
▪ Respiratory rate; temperature; blood pressure; pulse; oxygen saturation
Glasgow Coma Scale, Full clinical examination, etc
▪ Establish monitoring regimen
▪ Consider and precipitating causes and treat appropriately
http://www.bsped.org.uk/professional/guidelines/docs/DKAGuideline.pdf
 Emergency care of DKA

▪ 60 minutes to 6 hours
Aims of treatment:
• Rate of fall of ketones of at least 0.5 mmol/L/hr OR bicarbonate rise 3 mmol/L/hr and blood
glucose fall 3 mmol/L/hr
• Maintain serum potassium in normal range
• Avoid hypoglycaemia
▪ Actions:
▪ Re-assess patient, monitor vital signs
▪ Continue fluid replacement via infusion pump
▪ Assess response to treatment
http://www.bsped.org.uk/professional/guidelines/docs/DKAGuideline.pdf
 Emergency care of DKA

▪ 6 to 12 hours
Aims:
• Ensure clinical and biochemical parameters improving
• Continue iv fluid replacement
• Avoid hypoglycaemia
• Assess for complications of treatment e.g. fluid overload, cerebral oedema
• Treat precipitating factors as necessary

▪ Actions:
▪ Re-assess patient, monitor vital signs
▪ Review biochemical and metabolic
http://www.bsped.org.uk/professional/guidelines/docs/DKAGuideline.pdf
 Emergency care of DKA

12 to 24 HOURS
Aim:
▪ Ensure that clinical and biochemical parameters are continuing to improve or are normal
▪ Continue iv fluid replacement if not eating and drinking.
▪ If ketonemia cleared and patient is not eating and drinking move to a variable rate IVII as per local guidelines
▪ Re-assess for complications of treatment e.g. fluid overload, cerebral oedema
▪ Continue to treat precipitating factors
▪ Transfer to subcutaneous insulin if patient is eating and drinking normally.

Actions:
▪ Action 1 – Re-assess patient, monitor vital signs
▪ Action 2 – Review biochemical and metabolic parameters
Evidence Base
(Alghamdi et al, 2022)

Conclusion
The use of saline may be associated
with longer time to DKA resolution,
higher post-resuscitation plasma
chloride levels, lower post-
resuscitation plasma bicarbonate
levels, and longer hospital stay
compared with balanced
crystalloids. 
Hyperosmolar hyperglycemic
syndrome
 Definitions
Cause of Death in Adults: Underlying
illness (not uncommon)

▪ Blood glucose >600mg/dl

▪ arterial ph>7.3
▪ bicarbonate >15
▪ effective serum osmolality >320 mOsm/kg H20
▪ mild ketonuria or ketonemia may be present
Diagnostic criteria for DKA and HHS

▪ https://doi.org/10.2337/dc06-9916
Definition and Diagnosis (Joint British Diabetes
Societies for Inpatient Care (JBDS-IP)
 Development of Hyperosmolar
Hyperglycaemic States and
Goals of Treatment
▪ Normalise the osmolality
▪ Replace fluid and electrolyte losses
▪ Normalise blood glucose
• IV fluid replacement with normal saline to
maintain the circulating volume and tissue
perfusion;
• Oxygen therapy;
• Bicarbonate given early to correct the
acidosis and should be administered slowly to
avoid causing metabolic alkalosis and
ventilatory failure.
management pathway of DKA and HHS 
Hypoglycemia
 Definitions

Hypoglycemia is defined by its clinical presentation,

characterized by the classical triad of Whipple , i.e.,
symptoms/ signs compatible with low plasma glucose
concentration, low plasma glucose measurement (usually
between 65 – 70 mg/dL [3.6 – 3.9 mmol/L]), and resolution
of symptoms after increase of blood glucose level.
 Clinical Presentation of Hypoglycaemia

▪ https://doi.org/10.1016/j.tem.2020.05.008
 Hypoglycemia Treatment (ADA, 2016)

▪ Hypoglycemia treatment requires ingestion of glucose- or carbohydrate-containing

foods.
▪ Glucagon should be prescribed for all individuals at increased risk of severe
hypoglycemia, defined as hypoglycemia requiring assistance, and caregivers or family
members of these individuals should be instructed on its administration
▪ Glucose (15–20 g) is the preferred treatment for the conscious individual with
hypoglycemia, although any form of carbohydrate that contains glucose may be used.
▪ In general, guidelines and studies were somewhat concordant and recommended 15–
20 g of oral glucose or sucrose, repeated after 10–15 min for treatment of the
responsive adult, and 10% intravenous dextrose or 1 mg intramuscular glucagon for
treatment of the unresponsive adult.
International guidelines/recommendations for treatment of
hypoglycaemia in adults
 Nursing care with Diabetes Emergencies

▪ KEY QUESTIONS:
▪ Name • Age • Onset • Allergies • Prior History
• Severity • Pain Scale • Vital Signs • Oxygen Saturation
• Serum Glucose Level • Medications
• Insulin Pump • Homecare Measures

▪ RELATED PROTOCOLS:
▪ Altered Mental Status • Fever • Wound Infection
Nursing care with Diabetes Emergencies

ACUITY LEVEL/ASSESSMENT NURSING CONSIDERATIONS

Level 1: Critical Resuscitation
Apnea or severe respiratory distress
Refer for immediate treatment
Hypotension
Many resources needed
Unresponsive
Staff at bedside
Pale, diaphoretic, and lightheaded or weak
Mobilization of resuscitation team
Seizure

Briggs, J.K., & Grossman, V.A. (2020). Emergency nursing: 5-tier triage protocols. Second Edition. New York:
Spinger Publishing
Nursing care with Diabetes Emergencies

ACUITY LEVEL/ASSESSMENT NURSING CONSIDERATIONS

Level 2: High Risk
Altered mental status
Intractable vomiting
Blood glucose <60 mg/dL
Hypoglycemic infant
Insulin overdose
Severe dehydration
Emergent
Do not delay treatment
Notify physician
Multiple diagnostic studies or procedures
Frequent consultation
Constant monitoring
Measure serum glucose level
Nursing care with Diabetes Emergencies

ACUITY LEVEL/ASSESSMENT NURSING CONSIDERATIONS

Level 3: Moderate Risk Urgent
Severe pain
Blood glucose >400 mg/dL or <80 mg/dL
Rapid respiratory rate
Refer for treatment as soon as possible
Fruity breath odor
May need multiple diagnostic studies or
Lightheaded
procedures
Profuse diaphoresis
Monitor for changes in condition
Wound with signs of infection: drainage, fever,
If vital signs abnormal, consider Level 2
red streaks, or pus
Measure serum glucose level
Persistent vomiting and inability to keep down medication
Noncompliant with taking insulin or oral medication and feels
ill
Nursing care with Diabetes Emergencies

ACUITY LEVEL/ASSESSMENT NURSING CONSIDERATIONS

Level 4: Low Risk Semi-Urgent

Moderate pain
Reassess while waiting, per facility protocol
Slow healing wound
Offer comfort measures
Upper respiratory infection with fever and cough
May need a simple diagnostic study or procedure
Headache or nausea and prolonged period since last meal

Nonurgent
Level 5: Lower Risk

Request for prescription refill

Reassess while waiting, per facility protocol
New-onset insulin-dependent diabetes mellitus
Offer comfort measures
and requests additional education for
May need examination only
self-administration of insulin