• Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) are the main hyperglycemic emergencies.
• DKA has a higher incidence in type 1 diabetes.
• HHS is more common in older patients with type 2 diabetes.
• Mortality is often related to the underlying precipitant, electrolyte abnormalities, cerebral edema, the degree of dehydration, and older age.
• Treatment of DKA and HHS is focused on fluid resuscitation, addressing potassium imbalances, correcting ketoacidosis (in DKA), normalizing glucose and other electrolyte levels, addressing the underlying precipitant, and preventing complications.
• Stress-induced hyperglycemia is a transient response that may be present in acutely ill patients (e.g., sepsis, trauma, burns).
• Hyperglycemic patients without DKA or HHS are likely to be discharged after management in the emergency department with appropriate follow-up.

Note: Individual health authorities may have standardized DKA and/or HHS order sets.

Management of Hyperglycemia (NO DKA or HHS)

Previously undiagnosed diabetes

• Severe and symptomatic hyperglycemia – administer insulin (both a low dose of regular or rapid-acting insulin and long-acting insulin) – consult endocrine or internal medicine.
• Type 2 Diabetes (T2DM) diagnosed in ED – control acute symptoms, address any underlying precipitant/cause and consider prescribing metformin 500mg BID (contraindicated if GFR < 30mL/min) and/or referring to primary care provider for urgent follow-up. If the patient has no acute symptoms of hyperglycemia, arrange follow-up within a week.

Hyperglycemia in Type 1 Diabetes (T1DM) with no acute symptoms
Consider referring to the patient’s primary physician for medication adjustment. Any change to basal and rapid-acting insulin doses in the ED should consider the degree of hyperglycemia and time passed since the last meal.

Severe hyperglycemia in T2DM
Give fluids and IV insulin, correct electrolyte imbalances and address any underlying cause.

Glucose Control

• There is a lack of consensus regarding the importance of achieving glycemic control in the ED for patients well enough for discharge. A recent study showed no significant difference in short-term adverse outcomes when comparing moderate (< 19.4mmol/L) or loose (< 33.3mmol/L) ED glycemic control in patients with T2DM and hyperglycemia.

DKA Management

View: Diabetes Canada Management Algorithm of DKA in Adults.

• IV fluids (first priority).
• Treat shock more aggressively (normal saline 1-2L/h). ~ 6-8 liter deficit.
• In patients without shock or once shock is resolved, give normal saline 500mL/h for 4 hours, followed by 250mL/h for 4 hours.
• When euvolemia is achieved, switching to 0.45% normal saline to replace losses is recommended if corrected [Na⁺] is normal/high and plasma osmolality is decreasing at a rate <3mmol/kg/h.
• Maintain a plasma glucose of 12.0-14.0mmol/L with IV dextrose (D5W, D10W) to prevent hypoglycemia while continuing insulin to close the anion gap (see “acidosis” below).
• Note – Large volumes of normal saline carry the risk of hyperchloremic metabolic acidosis. Ringer’s lactate or plasmalyte are options.
• Potassium (second priority).
• Serum [K⁺] is typically normal/high in patients with DKA and HHS, despite being total body K⁺ Watch for hypokalemia during treatment as K⁺ shifts back into intracellular space.
• Supplement immediately if normo- or hypokalemic (give 40mmol/L KCl if [K⁺] < 3.3mmol/L; give 10-40mmol/L KCl if [K⁺] >3.3mmol/L to <5.0-5.5mmol/L).
• If hyperkalemic, supplement if [K⁺] drops below 5.0-5.5 mmol/L and there is diuresis.
• Correct hypokalemia before starting insulin (ensure [K⁺] ≥ 3.3mmol/L).
• Additional considerations:
  • Conservative administration in patients with renal failure.
  • Oral potassium can be used once this route is tolerated by the patient.
  • Cardiac monitoring in severe hypokalemia.
  • Acidosis.

• Give IV short-acting insulin (Humulin R) 0.1 units/kg/h until the anion gap is normalized. Prevention of hypoglycemia is achieved through IV dextrose.
• No bolus.
• For patients in shock or with a pH < 7.0 consider giving sodium bicarbonate.
• Additional considerations:
  • Avoid abruptly stopping IV insulin. Ensure appropriate transition of insulin therapies to prevent relapse (i.e. sufficient overlap of IV and SC).
  • If a patient with DKA has an insulin pump, disconnect and rely on IV insulin.
  • Treat precipitating cause.

HHS Management

• The treatment is similar to DKA. Individualized IV fluid administration is recommended as older patients. Potassium can be managed as per DKA. IV insulin (at similar doses to DKA) is still recommended; however, the role of insulin is primarily to help normalize glucose levels.
• BS can drop precipitously. Monitor closely initially.
• Serum osmolality – a rate of fall ≥3mmol/kg/h should be avoided due to risk of cerebral edema.

Monitoring in DKA and HHS

• Glucose should be checked hourly. Capillary BG can guide treatment between serum level checks.
• At least every 2 hours, the response to therapy should be assessed through vitals and level of consciousness, volume status and intake/output, insulin dosage, and repeat labs (glucose, electrolytes, bicarbonate, pH, anion gap, osmolality).

Not recommended in DKA and HHS

• Administration of an initial insulin bolus (lack of evidence in adults).
• Routine phosphate therapy in DKA (lack of evidence).
• Routine administration of bicarbonate (associated risks).

Complications of DKA and HHS

• Hypoglycemia (most common complication of treatment).
• Hyper/hypokalemia.
• Volume overload.
• Cerebral edema (high-risk groups: young patients, new-onset diabetes).
• Acute respiratory distress syndrome.
• Hypophosphatemia.
• Hyperchloremic metabolic acidosis (Saline resuscitation).
• Venous Thromboembolism.

Note: This summary does not cover management of hyperglycemia in children. Refer to the Related Information section for relevant links.

• Most patients diagnosed with DKA or HHS require admission.
• Acute hyperglycemia that is not resolving with treatment or is associated with significant volume depletion.
• Patients with newly identified severe/symptomatic hyperglycemia (or consider observation unit).

Patients with DKA or HSS presenting to rural centers without ICUs or sufficient resources for appropriate management and monitoring will likely require transfer or consultation. Likewise, if the precipitating cause requires a higher level of specialized care than that which is locally available, transfer may be indicated.

• Most patients diagnosed with DKA or HHS should be admitted to an ICU or step-down unit for management and close monitoring.
• Patients with newly identified severe/symptomatic hyperglycemia should be monitored in an observation unit (or admitted).

Evidence and protocols regarding appropriate glucose levels for the safe ED discharge of noncritically ill patients with hyperglycemia are lacking.

Discharge Considerations

• Arranging outpatient follow-up is important for the care of these patients, particularly among young populations where challenges with the transition to adult care can impact compliance and hinder adequate glycemic control.
• Consider involving a social worker to help address the social and economic barriers patients may be facing that impact the ability to adhere to treatment regimens.
• Consider referral to diabetes clinic/clinical diabetes educator/diabetic care team.
• Patients with stress-induced hyperglycemia should be closely followed once discharged, as they are at increased risk of developing incident type 2 diabetes.
• Encourage and arrange follow-up with primary care provider for sick-day planning focused on which medications to hold, appropriate adjustment of antihyperglycemics, the need for increased glucose monitoring, and when to seek medical care.

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

   
   

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

   
   

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

   
   

4. Nyce A, Byrne R, Lubkin CL, Chansky ME. Diabetic ketoacidosis. In: Tintinalli JE, Ma OJ, Yealy DM, Meckler GD, Stapczynski JS, Cline DM, Thomas SH, eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 9^th ed. McGraw-Hill; 2020. Accessed April 17, 2021.

   
   

5. Fayfman M, Pasquel FJ, Umpierrez GE. Management of hyperglycemic crises diabetic ketoacidosis and hyperglycemic hyperosmolar state. Med Clin N Am. 2017;101:587-606. doi:10.1016/j.mcna.2016.12.011

   
   

6. Yan JW, Hamelin AL, Gushulak KM, Van Aarsen K, Columbus MP, Stiell IG. Hyperglycemia in young adults with types 1 and 2 diabetes seen in the emergency department: A health records review. Can J Diabetes. 2018;42:296-301.e5. doi: 10.1016/j.jcjd.2017.06.016

   
   

7. Pourmand A, Mazer-Amirshahi M, Caggiula A, Nawab A, Payette C, Johnson S. Targeted glycemic control for adult patients with type 2 diabetes mellitus in the acute care setting. Can J Diabetes. 2018;42:671-677. doi:10.1016/j.jcjd.2018.01.015

   
   

8. Mifsud S, Schembri EL, Gruppetta M. Stress-induced hyperglycaemia. Br J Hosp Med. 2018;79(11):634-639. doi:10.12968/hmed.2018.79.11.634

   
   

9. Alberta Health Services. Provincial clinical knowledge topic: Diabetic ketoacidosis, adult emergency department. Revised March 2016. Accessed May 4, 2021.

   
   

10. Driver BE, Klein LR, Cole JB, Prekker ME, Fagerstrom ET, Miner JR. Comparison of two glycemic discharge goals in ED patients with hyperglycemia, a randomized trial. The American journal of emergency medicine. 2019;37:1295-1300. doi: 10.1016/j.ajem.2018.09.053

    
    

1. Northern Heath – Diabetes Education Centres.

   
   

2. EM Cases Podcast: Ep 147 HHS Recognition and ED Management.

   
   

3. EM Cases Podcast: DKA Recognition and ED Management.