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.

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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.

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Diabetic Ketoacidosis (DKA)

Definition: Hyperglycemic crisis characterized by:

• Blood glucose > 250 mg/dL
• Arterial pH < 7.30
• Serum bicarbonate < 18 mEq/L
• Presence of ketones in blood/urine

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 (most common trigger)
• Insulin missed or inadequate
• 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

Priority Order: Fluids → Insulin → Potassium → Treat Cause

1. Fluid Resuscitation (First Priority)

• Initial: 0.9% NS 1-1.5 L in first hour
• Subsequent: 250-500 mL/hour based on hydration status
• Switch to 0.45% NS when Na+ normalizes
• Add D5W when glucose reaches 200-250 mg/dL (prevents hypoglycemia during insulin therapy)

2. Insulin Therapy

• IV Regular insulin only (do not use rapid or long-acting)
• Bolus: 0.1 units/kg
• Continuous drip: 0.1 units/kg/hour
• Goal: Decrease glucose by 50-75 mg/dL/hour
• Too rapid decrease can cause cerebral edema

3. Potassium Replacement

Critical: Always check potassium BEFORE starting insulin!

Why potassium is critical: Insulin drives potassium INTO cells. Starting insulin when K+ is low can cause fatal cardiac arrhythmias.

4. Treat Underlying Cause

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

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Comparing Hypoglycemia and DKA

Quick Memory Aid

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

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Hyperosmolar Hyperglycemic State (HHS)

Brief mention for comparison:

• Occurs in Type 2 diabetes
• Blood glucose often > 600 mg/dL
• No significant ketosis (enough insulin to prevent ketone formation)
• Severe dehydration and hyperosmolarity
• Treatment similar to DKA but may need less insulin

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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

• Continuous glucose monitoring (hourly during treatment)
• Strict I&O with Foley catheter
• Telemetry monitoring (potassium affects heart)
• Neurological checks for cerebral edema
• Blood glucose checks hourly; electrolytes every 2-4 hours

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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 D5W when glucose reaches 200-250 mg/dL during DKA treatment