Diabetic Emergencies: New Strategies For An Old Disease
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Diabetic Emergencies: New Strategies For An Old Disease

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Table of Contents
 
Table of Contents
  1. Abstract
  2. Case Presentations
  3. Introduction for Diabetic Emergencies
  4. Critical Appraisal Of The Literature for Diabetic Emergencies
  5. Etiology And Pathophysiology for Diabetic Emergencies
    1. Diabetes Mellitus Type 1
    2. Diabetes Mellitus Type 2
    3. Diabetic Ketoacidosis
    4. Hyperosmolar Hyperglycemic State
  6. Differential Diagnosis for Diabetic Emergencies
  7. Prehospital Care for Diabetic Emergencies
    1. Hypoglycemia
    2. Hyperglycemia
  8. Emergency Department Evaluation for Diabetic Emergencies
    1. History
    2. Physical Examination
  9. Diagnostic Studies for Diabetic Emergencies
    1. Hypoglycemia
    2. Hyperglycemia
      1. Sodium And Serum Osmolality
      2. Serum Potassium
      3. Serum Phosphate
      4. Serum pH And Anion Gap
      5. Serum Glucose
      6. Serum Ketones
      7. Urine Ketones
  10. Treatment for Diabetic Emergencies
    1. Diabetic Ketoacidosis
      1. Rehydration
      2. Insulin
        • Subcutaneous Insulin
      3. Correction Of Potassium
      4. Sodium Bicarbonate
    2. Hyperosmolar Hyperglycemic State
    3. Hypoglycemia
      1. Refractory Hypoglycemia
  11. Special Circumstances for Diabetic Emergencies
    1. Cardiac Arrest
    2. Metformin-Induced Lactic Acidosis
    3. Management Of New-Onset Diabetes
  12. Controversies And Cutting Edge
    1. New Oral Hypoglycemic Agent
  13. Disposition for Diabetic Emergencies
    1. Diabetic Ketoacidosis
    2. Hyperosmolar Hyperglycemic State
    3. Hypoglycemia
  14. Summary for Diabetic Emergencies
  15. Clinical Pathway For Management Of Diabetic Ketoacidosis In The Emergency Department
  16. Risk Management Pitfalls For Diabetic Emergencies
  17. Time- And Cost-Effective Strategies For Diabetic Emergencies
  18. Case Conclusions
  19. Tables and Figures
    1. Table 1. Etiologies Of Hyperglycemia
    2. Table 2. Etiologies Of Hypoglycemia
    3. Table 3. Common Drugs And Their Effects On Serum Glucose
    4. Table 4. Diagnostic Testing Considerations In Hypoglycemia And Hyperglycemia
    5. Figure 1. Electrocardiogram In A Patient With Hyperkalemia, Showing A Sine Wave Pattern
    6. Figure 2. Electrocardiogram In The Same Patient After Administration Of Calcium Gluconate
  20. References

Abstract

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.

Case Presentations

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!

Introduction for Diabetic Emergencies

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.

Critical Appraisal Of The Literature for Diabetic Emergencies

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

Risk Management Pitfalls For Diabetic Emergencies

  1. “I ordered a serum ketone, and it was mildly elevated. I was told later that the patient was in severe DKA.” The preferred laboratory value to examine for DKA is beta-hydroxybutyrate. In DKA, the ratio of the beta-hydroxybutyrate to acetoacetate or acetone changes in response to the increased ketones. Instead of 1:1, it increases to as much as 5:1 of beta-hydroxybutyrate to acetoacetate. Beta-hydroxybutyrate will more accurately reflect whether the patient is in DKA.
  2. “The elderly patient had HHS, but I thought the floor could handle him.” In patients with HHS, admission to the intensive care unit is prudent, given that they will be on insulin drips and because of their underlying medical conditions. If a patient has few or no underlying medical conditions and responds well to management in the ED as observed through laboratory tests and vital signs, then it may be reasonable to admit the patient to a step-down unit.
  3. “The patient had family members with nausea, vomiting, and diarrhea. I didn’t think that his diabetes was the cause of his nausea and vomiting.” Have a low threshold for checking blood sugar and a basic metabolic profile. The etiology of the diabetic emergency can be from a viral illness or some other physiologic stressor.
  4. “The patient had HHS, but also a history of congestive heart failure, so I started him on an insulin infusion but held back the fluids. I thought treating the hyperglycemia alone would help resolve the patient’s tachycardia.” Patients with HHS have an average deficit of 8 to 10 liters of fluid. Rehydration is a key initial management strategy in treating this ailment. Both hydration and insulin would have helped manage this patient’s pathology.
  5. “The patient who had DKA received 9 liters of fluid and then started to develop mental status changes.” Although rare, cerebral edema does develop in adults. Using the correct rehydration may reduce the risk of this devastating illness.68 Mannitol may be considered once neurological symptoms occur.31,99 Additionally, fluid infusion rates should be decreased and the head of the bed should be elevated. An alternative to mannitol is hypertonic saline, which can be given at a dose of 5 to 10 mL/kg of 3% saline over 30 minutes.100,101 Risk Management Pitfalls For Diabetic Emergencies
  6. “The patient’s potassium was elevated and he was in DKA, so I gave him kayexalate.” In DKA, the serum potassium may be elevated, but unless there are ECG changes, the management for the elevated potassium is to manage the DKA. The insulin infusion will allow the potassium to transition intracellularly, thereby decreasing the serum potassium. If the potassium is decreased prior to the insulin infusion, the patient may become hypokalemic and develop life-threatening dysrhythmias.
  7. “The patient was diabetic, and I checked his serum glucose and it was not elevated; therefore, he could not be in DKA.” A patient may have DKA with a normal blood sugar. This pathology is referred to as euglycemic DKA. Typically, the patient has vomiting, but continues to use his/her insulin. In this situation, the beta-hydroxybutyrate levels will be crucial to the successful diagnosis of DKA.
  8. “I knew the patient was in DKA, so I started the insulin infusion. I did not know that his potassium of 2.8 mEq/L was going to be problematic.” Patients in DKA tend to have a normal to low body potassium level. If the serum potassium is < 3.3 mEq/dL, then the initial management strategy is to administer fluids with potassium intravenously; once the serum potassium is ≥ 3.3 mEq/dL, then the insulin infusion can be initiated. If this is not done, the patient may develop life-threatening dysrhythmias from the hypokalemia. Repletion of potassium can be achieved by infusing potassium at 20 to 30 mEq/h, usually mixing 40 to 60 mEq of potassium in a liter of half-normal saline.67,68
  9. “The patient’s blood sugar improved and she was tolerating food, so I discharged her. She was on a sulfonylurea, but her vitals looked fine.” In diabetics who are using sulfonylureas, admission is generally advisable due to the high risk of recurrence of hypoglycemia. This is especially true with the longer-acting sulfonylureas.
  10. “There were no intensive care unit beds and the ED was very busy. I kept the patient with DKA on the normal saline infusion and insulin, but I didn't expect him to become so hypoglycemic.” When the serum glucose is 200 mg/dL, consider decreasing the insulin infusion rate from 0.1 or 0.14 units/kg/h to 0.02 to 0.05 units/kg/h and adding dextrose to the infusing fluids. If this is not done, the patient’s glucose can drop too rapidly and hypoglycemia may ensue.

Tables and Figures

Table 1. Etiologies Of Hyperglycemia

Table 2. Etiologies Of Hypoglycemia

References

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.

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Authors

Gerald Beltran, DO, MPH

Publication Date

June 2, 2014

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