CuraRN

Diabetic Emergencies (DKA, HHS)

Student study notes from paramedic coursework (2023 to 2024), not medical advice. Verify clinical values against current references and your local protocols.

EMS etiologies

Setting: ER

Hyperglycemia

Hyperglycemia means a fasting blood glucose greater than 126 mg/dL or a postprandial (after eating) blood glucose greater than 200 mg/dL

Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) are severe complications of diabetes, often triggered by infection, illness, or inadequate insulin.

Diabetic ketoacidosis (DKA)

Diabetic ketoacidosis (DKA) is a serious, potentially life-threatening complication of diabetes mellitus, most commonly associated with type 1 diabetes but can occur in other types. DKA is characterized by a rapid onset of symptoms, including vomiting, abdominal pain, deep gasping breathing (Kussmaul breathing), frequent urination, weakness, confusion, and in severe cases, loss of consciousness. A “fruity” odor in the breath is also a distinctive sign of DKA.

DKA occurs due to a severe insulin deficiency, which leads the body to use fatty acids for energy, producing acidic ketone bodies that accumulate in the blood and urine, causing acidosis. Triggers for DKA include infections, missed insulin doses, stroke, and certain medications like steroids.

Hyperosmolar Hyperglycemic State (HHS)

Hyperosmolar hyperglycemic state (HHS), also known as hyperosmolar non-ketotic state (HONK), is a serious complication of diabetes mellitus, most commonly associated with type 2 diabetes. It is characterized by extremely high blood sugar levels, leading to increased blood osmolarity without significant ketoacidosis, differentiating it from diabetic ketoacidosis (DKA).

The main risk factor for HHS is a history of type 2 diabetes, though it can occasionally occur in individuals without a prior diabetes diagnosis or in those with type 1 diabetes. Triggers for HHS include:

• Infections (e.g., pneumonia, urinary tract infections)
• Stroke
• Trauma
• Heart attacks
• Certain medications (e.g., steroids, diuretics)

HHS develops slowly over days to weeks, leading to symptoms such as severe dehydration, weakness, vision problems, leg cramps, and altered consciousness. It can result in serious complications, including seizures, blood clotting disorders (disseminated intravascular coagulation), mesenteric artery occlusion, and rhabdomyolysis.

Hypoglycemia

Hypoglycemia is often defined by a plasma glucose concentration below 70 mg/dL; however, signs and symptoms may not occur until plasma glucose concentrations drop below 55 mg/dL.

Causes:

• Pharmacologic: Most common cause of hypoglycemia, particularly in diabetic patients using medications like meglitinides, sulfonylureas, or insulin. Other drugs like metformin or GLP-1 agonists rarely cause hypoglycemia.
• Alcohol: Prolonged alcohol consumption can inhibit gluconeogenesis, leading to hypoglycemia once glycogen stores are depleted.
• Critical Illness: Conditions like liver disease, sepsis, starvation, or renal failure can cause hypoglycemia as glucose utilization exceeds production.
• Hormone Deficiencies: Adrenal insufficiency can lead to hypoglycemia due to a lack of cortisol, though this is rare.
• Non-Islet Cell Tumors: Tumors that increase insulin-like growth factor 2 (IGF-2) production can cause hypoglycemia.
• Insulinomas: These rare, hyperfunctioning islet cell tumors lead to excessive insulin secretion, causing fasting hypoglycemia.

Treatment of Hypoglycemia:

• Acute Management:
  • Severe hypoglycemia is treated with intravenous (IV) dextrose or glucagon (administered intramuscularly or intranasally) if the patient cannot take oral medication.
  • Conscious patients can be given oral carbohydrates, such as fruit juice.
  • Once stable, a complex carbohydrate should be provided to maintain blood sugar levels.
• Non-Pharmacological Management:
  • Patient education is key, focusing on recognizing symptoms, regular blood glucose monitoring, and carrying glucose sources.
  • Wearing a medical alert bracelet is recommended.
  • For diabetic patients, lifestyle adjustments and reviewing food and glucose logs are essential to prevent recurrent hypoglycemia.

• Pharmacological Adjustments: Medication regimens should be reviewed and modified if lifestyle changes are insufficient in preventing further episodes.

• Insulinomas: These are typically managed with surgical intervention, and further investigation for multiple endocrine neoplasia (MEN) disorders is recommended if an insulinoma is found.

Clinical Presentation:

• DKA: high blood sugar, ketones in urine, fruity breath, Kussmaul respirations
• HHS: extremely high blood sugar, severe dehydration, altered mental status
• hypoglycemia:
  • Autonomic Symptoms (Early)
    • Shakiness or tremors
    • Sweating
    • Anxiety or nervousness
    • Palpitations (rapid heartbeat)
    • Hunger
    • Pallor (pale skin)
  • Neuroglycopenic Symptoms (Late)
    • Confusion or difficulty concentrating
    • Dizziness or lightheadedness
    • Blurred vision
    • Weakness or fatigue
    • Headache
    • Irritability or mood changes
    • Slurred speech
    • Seizures
    • Loss of consciousness or coma (in severe cases)
  • Severe Hypoglycemia
    • Seizures
    • Loss of consciousness
    • Coma
    • Death if not treated promptly

Treatment Modalities:

• Intravenous fluids
• Insulin therapy
• Electrolyte replacement
• Monitoring and supportive care