Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) are the main hyperglycemic emergencies that should be considered for any patient with significant hyperglycemia.

• DKA more common than HHS with a higher incidence in type 1 diabetes.
• HHS more common in older type 2 diabetics and has a higher mortality rate.
• A high index of suspicion for these conditions is important as ~50% of deaths happen in the first 2-3 days.

Precipitants:

• Infection (e.g., UTI, pneumonia).
• Insulin reduction or omission (e.g., noncompliance, pump malfunction).
• New diabetes mellitus diagnosis.
• Acute illness (e.g., MI, stroke, thyrotoxicosis, pancreatitis).
• Trauma.

Medications:

• • Atypical antipsychotics.
  • Diuretics.
  • Steroids.
  • Lithium.
  • Beta-blockers.
  • Some chemotherapy agents.
  • Sglt2 inhibitors.

• Toxins (e.g., alcohol, cocaine).
• Pregnancy.
• May require admission to an ICU or step-down unit.

Not all patients with hyperglycemia have a history of diabetes or are subsequently diagnosed with diabetes. Stress-induced hyperglycemia can occur in acutely ill patients (e.g., sepsis, trauma, burns) and has increased morbidity and mortality.

Common clinical features:

• Hyperglycemia – polyuria, polydipsia, weakness, fatigue, weight loss, signs of volume depletion.
• DKA – acute onset; signs/symptoms of hyperglycemia, diffuse abdominal pain, nausea, vomiting, tachypnea (Kussmaul), acetone/fruity breath, altered LOC.
• HHS – insidious onset; signs/symptoms of hyperglycemia, decreased LOC, signs of severe volume depletion, seizures.
• Look for precipitating factor in both DKA and HHS.

Initial Assessment:

• Volume status.
• Level of consciousness.
• Look for precipitating factor(s).
• Assess for potential complications.

Investigations:

• Serum glucose. Capillary BG is not accurate in severe acidosis and interstitial glucose levels should not be used for diagnosis.
• Consider HbA1c (does not change acute management).
• If DKA or HHS is suspected:
  • Electrolytes.
  • Serum glucose.
  • Anion gap +/- lactate.
  • Creatinine.
  • Serum osmolality, Serum and urine ketones, beta-hydroxybutyric acid (if possible).
  • Venous Blood gases.
  • ECG – assess for acute coronary syndrome.
  • Additional tests can be guided by suspicion of precipitating factor(s).

• DKA:
  • Arterial pH ≤ 7.3.
  • Serum bicarbonate ≤ 15mmol/L.
  • Anion gap > 12mmol/L.
  • Positive urine/serum ketones.
  • Plasma glucose ≥ 14mmol/L.

• It’s important not to interpret these values as hard and fast rules as there are exceptions to each:
  • Ketones may be negative if beta-OHB production is favored.
  • Bicarbonate may be normal/high if there’s a concomitant severe metabolic alkalosis.
  • Normoglycemia is possible with SGLT2 inhibitor use, in pregnancy, if insulin was just given, in T1DM with vomiting, or in cases of starvation, alcohol abuse, or liver failure.

• HHS:
  • BG ≥ 34mmol/L.
  • Serum osmolality > 320mOsm/kg.
  • Minimal/no acidosis (ketones can be present).
• Considerations for interpreting lab values:
  • Hyperglycemia causes osmotic shifts of water from the intra- to extra-cellular space causing relative hyponatremia. Correction factor 1.6 mEq/L for every 5.5 mmol/L BS above normal (another source uses 2.4 mEq/L).
  • Often total body K⁺ depleted, but serum K⁺ is typically normal/high initially due to the shift of K⁺ to extracellular space.
  • Serum PO4^3-, Ca²⁺ and Mg²⁺ may also be high despite total body depletion.
  • Some substances (e.g., acetaminophen, ascorbic acid, peritoneal dialysis) can lead to false increases in capillary and home blood glucose monitoring tests.
  • Nitroprusside test for ketones does not measure beta-hydroxybutyric acid.

Diagnosis of Diabetes:

Diabetes Canada: an adult with symptomatic hyperglycemia can be diagnosed with diabetes if they have 1 of the following:

• Fasting BG ≥ 7.0mmol/L.
• HgB A1C ≥ 6.5%.
• 2h BG in a 75g OGTT ≥ 11.1mmol/L.
• Random BG ≥ 11.1mmol/L.

Stress-induced Hyperglycemia:

• HbA1c can help distinguish stress-induced hyperglycemia from newly diagnosed diabetes.
• Patients with known diabetes can experience stress-related hyperglycemia.

1. Diabetes Canada 2018 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada: Hyperglycemic Emergencies in Adults. 
   Diabetes Canada Clinical Practice Guidelines Expert Committee, Goguen J, Gilbert J.  2018;42(Suppl 1):S109-S114.
   –Canadian  Journal of Diabetes.

   
   

2. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 
   Goyal N, Schlichting A. Type 1 diabetes mellitus. In: Tintinalli JE, Ma OJ, Yealy DM, Meckler GD, Stapczynski JS, Cline DM, Thomas SH, eds. 9^th . 2020.  Accessed April 17, 2021.
   –McGraw-Hill

   
   

3. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. Diabetic ketoacidosis. In: Tintinalli JE, Ma OJ, Yealy DM, Meckler GD, Stapczynski JS, Cline DM, Thomas SH, eds.  9^th ed. 2020.  Accessed April 17, 2021.
   –McGraw-Hill

   
   

4. Diabetes Canada 2018 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada: Definition, classification and diagnosis of diabetes, prediabetes and metabolic syndrome.
   Diabetes Canada Clinical Practice Guidelines Expert Committee, Punthakee Z, Goldenberg R, Katz P. . 2018;42(Suppl 1):S10-S15. 
   —Canadian  Journal of Diabetes.

   
   

5. Management of hyperglycemic crises: Diabetic ketoacidosis and hyperglycemic hyperosmolar state
   Fayfman M, Pasquel FJ, Umpierrez GE. . Med Clin N Am. 2017;101(3):587-606. 

   -Pubmed

   
   

6. Stress-induced hyperglycemia
   Mifsud S, Schembri EL, Gruppetta M. . Br J Hosp Med. 2018;79(11):634-639. 
   -Pubmed

   
   

1. Northern Heath – Diabetes Education Centres

   
   

2. Podcasts:

   Emergency Medicine Cases – HHS Recognition and ED Management:

   Emergency Medicine Cases – DKA Recognition and ED Management:

   
   

3. Related Information on BC EM Network Website:

   DKA Update