Diabetic emergencies are common in patients with diabetes, and the effects can be devastating. Hypoglycemia and hyperglycemia represent two extremes in the emergency presentations of the diabetic patient. This edition of Emergency Medicine Practice reviews the acute management of two of the most serious hyperglycemic disorders—diabetic ketoacidosis (DKA) and hyperglycemichyperosmolar syndrome (HHS)—and the controversy that surrounds the management of these diseases.

Over 100,000 cases of DKA, 5000 cases of diabetic coma, and 10,000 cases of hyperosmolar coma were recorded in the United States between 1989 and 1991.²

DKA is the most common cause of diabetes-related death in childhood and is a significant cause of mortality in adults.¹⁰¹ There is considerable overlap—about one-fifth to one-third of patients with otherwise classic DKA will also have hyperosmolarity. About one-half to three-fourths of patients with uncontrolled diabetes will have an osmolarity of 320 mOsm or more.³

Despite the plethora of guidelines and protocols, all with meticulous details of fluid and electrolyte replacement and insulin therapy, the mortality of diabetic emergencies has remained unchanged for the past 10 years.¹¹¹ However, with continued emphasis on the timely and appropriate identification and management of diabetic emergencies, hopefully this trend may change.