9.5 Diabetic Emergencies (Hypoglycemia and DKA)

Diabetic Emergencies

Diabetic emergencies can be rapidly fatal if not recognized and treated promptly. Nurses must differentiate between hypoglycemia (too little glucose) and hyperglycemic crises (too much glucose) to provide appropriate intervention.

---

Hypoglycemia (Low Blood Sugar)

Definition: Blood glucose < 70 mg/dL

Hypoglycemia is the most immediately dangerous diabetic emergency because the brain depends on glucose for function.

Causes of Hypoglycemia

Signs and Symptoms

Think "Cold and Clammy" for hypoglycemia

Mild Hypoglycemia (50-70 mg/dL):

• Tremors, shakiness
• Sweating (diaphoresis)
• Tachycardia, palpitations
• Anxiety, irritability
• Hunger
• Pallor

Moderate Hypoglycemia (40-50 mg/dL):

• Confusion
• Difficulty concentrating
• Slurred speech
• Blurred vision
• Drowsiness
• Mood changes

Severe Hypoglycemia (< 40 mg/dL):

• Loss of consciousness
• Seizures
• Coma
• Death (if untreated)

Treatment: The Rule of 15

For Conscious Patients:

1. Give 15 grams of fast-acting carbohydrates:
   • 4 oz (1/2 cup) fruit juice
   • 4 oz regular soda (not diet)
   • 3-4 glucose tablets
   • 1 tablespoon honey or sugar
2. Wait 15 minutes
3. Recheck blood glucose
4. If still < 70 mg/dL, repeat steps 1-3
5. Once glucose > 70 mg/dL, eat a snack with protein and complex carbs

For Unconscious Patients:

• IV access available: D50W (Dextrose 50%) 25-50 mL IV push
• No IV access: Glucagon 1 mg IM or SubQ
• Position patient on side (aspiration precaution)
• Do NOT give oral glucose (aspiration risk)

Exam Tip: Never give oral glucose to an unconscious patient. If no IV access, give glucagon IM. Once the patient regains consciousness, follow with oral carbohydrates.

---

Diabetic Ketoacidosis (DKA)

Definition (2024 adult consensus report on hyperglycemic crises): all three must be present:

• Diabetes: blood glucose ≥ 200 mg/dL or a known history of diabetes, whatever the glucose (about 10% of patients present with euglycemic DKA, glucose < 200 mg/dL)
• Ketones: elevated (blood β-hydroxybutyrate ≥ 3.0 mmol/L is the preferred test)
• Acidosis: pH < 7.30 or serum bicarbonate < 18 mEq/L

DKA occurs primarily in Type 1 diabetes but can occur in Type 2 under stress.

Pathophysiology

1. Absolute or relative insulin deficiency
2. Body cannot use glucose for energy
3. Fat breakdown produces ketone bodies (acids)
4. Ketoacidosis develops
5. Osmotic diuresis causes severe dehydration
6. Electrolyte imbalances occur

Causes (The I's)

• Infection (one of the two most frequent triggers, especially urinary tract infection and pneumonia)
• Insulin missed or inadequate (the other most frequent trigger)
• Infarction (MI, stroke)
• Illness or stress
• Initial presentation of Type 1 diabetes

Signs and Symptoms

Think "Hot and Dry" for DKA

Laboratory Findings in DKA

Treatment of DKA

Mainstays (2024 adult consensus): fluid replacement, insulin, electrolyte (potassium) repletion, and treatment of the precipitating cause. Check potassium before the insulin starts.

1. Fluid Resuscitation

• Initial (adults without kidney or heart compromise): isotonic saline or a balanced crystalloid at 500-1,000 mL/hour for the first 2-4 hours
• Older adults, heart failure, or dialysis-dependent kidney disease: smaller boluses (for example, 250 mL) with frequent hemodynamic checks
• Afterward: fluid choice and rate follow hydration status (blood pressure, heart rate, intake and output) and sodium
• When glucose falls below 250 mg/dL: add 5-10% dextrose to the saline (prevents hypoglycemia while insulin continues until the ketoacidosis resolves)

2. Insulin Therapy

• Preferred: short-acting (Regular) insulin by continuous IV infusion, usually a fixed rate of 0.1 units/kg/hour or a nurse-driven variable-rate protocol
• Bolus: 0.1 units/kg IV or IM when a delay in IV access is anticipated
• Uncomplicated mild or moderate DKA: subcutaneous rapid-acting insulin analogs every 1-2 hours are an effective alternative
• Once glucose is below 250 mg/dL, the infusion is usually reduced (about 0.05 units/kg/hour) to keep glucose near 200 mg/dL until the ketoacidosis resolves
• Cerebral edema is rare in adults; rapid shifts in osmolality may contribute, so watch for mental status changes

3. Potassium Replacement

Critical: Always check potassium BEFORE starting insulin!

Recheck potassium 2 hours after insulin starts, then every 4 hours until the DKA resolves.

Why potassium is critical: Insulin drives potassium INTO cells. Starting insulin when K+ is low can cause life-threatening cardiac arrhythmias and respiratory muscle weakness.

4. Treat Underlying Cause

• Antibiotics for infection
• Address medication non-compliance
• Patient education

---

Comparing Hypoglycemia and DKA

Quick Memory Aid

• Hypoglycemia = Cold and Clammy, need some Candy
• DKA = Hot and Dry, Sugar High

---

Hyperosmolar Hyperglycemic State (HHS)

Brief mention for comparison:

• More often seen in older adults with type 2 diabetes (it can occur with any type)
• Blood glucose often > 600 mg/dL
• No significant ketoacidosis, though mild ketonemia may be present; DKA and HHS overlap in more than a third of hyperglycemic crises
• Severe dehydration and hyperosmolarity
• Treatment similar to DKA but may need less insulin

---

Nursing Considerations

For Hypoglycemia

• Check blood glucose before treating if possible (but do not delay treatment)
• Teach patients to always carry fast-acting glucose
• Review medication and meal timing
• Educate on symptoms and self-treatment

For DKA

• Capillary blood glucose checks every 1-2 hours during treatment
• Strict intake and output
• Telemetry monitoring (potassium affects heart)
• Neurological checks (report any change in mental status)
• Electrolytes, phosphate, creatinine, β-hydroxybutyrate and venous pH about every 4 hours; potassium 2 hours after insulin starts, then every 4 hours

---

Key Points for the NCLEX

• Hypoglycemia is an immediate emergency - treat first, verify later if needed
• Rule of 15: 15g carbs, wait 15 minutes, recheck
• Unconscious patient: IV D50W or IM glucagon - never oral glucose
• DKA: Fluids FIRST, then insulin
• Check potassium before starting insulin in DKA
• Kussmaul respirations and fruity breath = DKA
• Add 5-10% dextrose once glucose falls below 250 mg/dL during DKA treatment