Diabetic emergencies are common presentations to the emergency department. It is estimated that diabetes affects 25.8 million people in the United States, at an annual total cost of over $174 billion. There are 2 general categories of diabetic emergencies: hyperglycemic and hypoglycemic. The hyperglycemic emergencies include diabetic ketoacidosis and hyperosmolar hyperglycemic state. Management of these conditions requires a careful hydration strategy to restore volume and improve perfusion, intravenous insulin therapy, and electrolyte monitoring. Management of hypoglycemia includes identification of the underlying etiology, oral food and/or glucose, intravenous dextrose, and consideration of glucagon. This review evaluates the current strategies for management of diabetic emergencies and offers new information regarding effective diagnostic strategies, selection of fluids for rehydration, correction of potassium, the use of subcutaneous insulin for mild hyperglycemia, and management of metformin-induced lactic acidosis.
You walk into a busy Monday evening shift, and one of the nurses asks you to see a patient who has been waiting for several hours. The nurse states that the 26-year-old woman is sleepy, with a heart rate of 126 beats/min. He advises you that the patient has diabetes, for which she has been medically compliant by taking her insulin. The patient stated that she had not been feeling well for a few days, after which she developed fever, nausea, and vomiting. As you enter the room, you observe the patient retching. You note her respiratory rate is 32 breaths/min, her heart rate is 124 beats/min, and that her blood pressure is 88/50 mm Hg. You start considering your differential and wonder if this presentation is due to her diabetes or if there is something else you might be missing.
After giving your orders on the first patient, a nurse requests that you see a 56-year-old man who is unresponsive. You enter the room and note that the patient's blood pressure is 110/60 mm Hg, respiratory rate is 16 breaths/ min, and heart rate is 110 beats/min. He also appears mildly diaphoretic. As you glance though the patient’s chart, you note that he has a history of diabetes. There are no family or friends in the patient’s room, and EMS has already departed to another call. Since the airway is always your first priority in unresponsive patients, you begin to prepare for intubation when a medical student asks what the patient’s finger-stick glucose was.
Your next patient is an 87-year-old man with diabetes who has been compliant with his medicines and is being treated for pneumonia that developed about a week ago. His primary care physician started him on an oral antibiotic and sent him home with strict instructions to return if his symptoms worsened. He has been taking his antibiotics as prescribed; however, he continues to have fevers, and today he felt progressive, generalized weakness with malaise. His family notes that he has also been getting more confused over the last few days. You request a STAT finger-stick glucose and realize that this Monday shift is going to be a long one!
Diabetes is estimated to affect 6% of the world’s population, with more than 97% having type 2 diabetes.1 The prevalence of diabetes has increased almost 700% in the United States since 1958. In 2010, diabetes affected the lives of 25.8 million people in the United States, which is about 8.3% of the United States population. Of those affected, about 18.8 million carry the diagnosis of diabetes, with 7 million people later being diagnosed as diabetic.1
According to the Centers for Disease Control and Prevention (CDC), diabetes carried an annual cost of about $174 billion in 2007, with approximately $116 billion for direct medical costs and $58 billion for indirect costs (such as loss of wages, disability, and mortality). The cost to society is substantial, since patients with diabetes have twice the medical expenses compared to patients of a similar age without diabetes. In terms of mortality, the CDC recognizes diabetes as the seventh leading cause of death, and patients with diabetes have death rates 2 to 4 times higher than those without diabetes.1 The morbidity associated with diabetes is also substantial. The risk for stroke is 2 to 4 times higher than for those without diabetes. Diabetes is the primary etiology of vision loss and blindness among adults in the United States.1 Similarly, diabetes is the primary etiology of kidney failure. In 2008, 44% of all new cases of renal failure were attributable to diabetes.1 Recent data estimate that 60% to 70% of people with diabetes also have nervous system injury from their disease.1 Examples of nervous system injury include neuropathy of the hands and/or feet, erectile dysfunction, and gastroparesis. Neuropathy, combined with poor wound healing, contribute to lower-extremity amputation. About 60% of nontraumatic lower-extremity amputations are sequelae of diabetes.1
With these financial and health impacts, diabetes carries substantial costs to both society and the individual. In the emergency department (ED), successful management of these patients reduces mortality and morbidity. This issue of Emergency Medicine Practice examines the best evidence available on the evaluation and management diabetic emergencies and provides best-practice management recommendations.
A literature review was conducted utilizing MEDLINE ® and PubMed. The following keywords were used for the MEDLINE® search; the number of articles that were identified are presented in parentheses: diabetic emergencies (73), diabetic ketoacidosis and treatment and hyperosmolar hyperglycemia (3), sulfonylurea and hypoglycemia (932), potassium and diabetic ketoacidosis (75), fluids and diabetic ketoacidosis (51), fluids and hyperosmolar hyperglycemia (0), diabetic ketoacidosis treatment (11), hyperosmolar hyperglycemia treatment (0), hypoglycemia treatment (30), sodium bicarbonate and diabetic ketoacidosis (95), and factitious hypoglycemia (67). The following keywords were used for the PubMed search: diabetic emergencies (421), diabetic ketoacidosis and treatment and hyperosmolar hyperglycemia (112), sulfonylurea and hypoglycemia (2099), potassium and diabetic ketoacidosis (78), fluids and diabetic ketoacidosis (65), fluids and hyperosmolar hyperglycemia (34), diabetic ketoacidosis treatment (3876), hyperosmolar hyperglycemia treatment (302), hypoglycemia treatment (18), sodium bicarbonate and diabetic ketoacidosis (131), and factitious hypoglycemia (129). Each of these articles was evaluated further only if written in English and based upon human studies. Once these criteria were applied, the articles were examined for relevance. The pertinent studies were then used as part of the review for this article.
In addition to these databases, the American College of Emergency Physicians clinical policies were reviewed, but no articles were found. Additionally, the Cochrane Library was searched for the following terms: DKA (36), diabetic ketoacidosis (3), hyperglycemia (15), and hyperosmolar hyperglycemia (0). Finally, the National Guideline Clearinghouse (www.guideline.gov) was searched for the following terms: DKA (18), diabetic ketoacidosis (19), hyperglycemia (88), and hyperosmolar hyperglycemia (12). Only articles written in English and based upon human studies were reviewed. Once these criteria were applied, the articles were examined for relevance.
There are many articles related to diabetic emergencies; however, most of these articles are reviews, and there are few well-designed studies to provide a high level of evidence on which to base clinical practice. Overall, the literature is based more upon consensus than on objective studies, with many of the evaluation and management strategies based more upon previous practice than on science. Recently, there have been several new research articles discussing evaluation and management strategies.2-7
Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.
To help the reader judge the strength of each reference, pertinent information about the study will be included in bold type following the reference, where available. In addition, the most informative references cited in this paper, as determined by the authors, will be noted by an asterisk (*) next to the number of the reference.
Gerald Beltran, DO, MPH
June 2, 2014