Skip to Main Content

Chapter 129: Diabetic Emergencies

Michael P. Kefer

HYPOGLYCEMIA

Hypoglycemia in diabetics is usually a complication of treatment with insulin or sulfonylureas (chlorpropamide, glyburide, glipizide). Hypoglycemia is unlikely due to the glitizones (rosiglitazone, pioglitazone), glinides (repaglinide, nateglinide), alpha-glucosidase inhibitors (acarbose, miglitol), and rare, if ever, due to the biguanide metformin, the incretin analogues (exenatide, liraglutide), or the amylin analogue pramlintide.

Clinical Features

Typical signs and symptoms of hypoglycemia include sweating, shakiness, anxiety, nausea, dizziness, palpitations, slurred speech, blurred vision, headache, seizure, focal neurologic deficits, and altered mental status ranging from confusion to coma.

Diagnosis and Differential

The diagnosis is based on detecting low blood glucose during the occurrence of typical signs and symptoms which resolve with treatment. Hypoglycemia can easily be misdiagnosed as a neurologic or psychiatric condition. The differential diagnosis includes stroke, seizure disorder, head injury, multiple sclerosis, psychosis, depression, and alcohol or drug intoxication.

Emergency Department Care and Disposition

  1. Administer glucose. Provide a carbohydrate meal when the patient can tolerate PO. Treat patients with altered mental status with 50% dextrose 50 mL IV. A continuous infusion of 10% dextrose solution may be required to maintain the blood glucose above 100 mg/dL.

  2. Administer glucagon 1 mg IM or SC if there is no IV access.

  3. Treat refractory hypoglycemia secondary to the sulfonylureas with octreotide 50 to 100 μg SC. A continuous infusion of 125 μg/h may be required.

  4. Repeat blood glucose every 30 minutes initially to monitor for rebound hypoglycemia.

  5. Disposition depends on the patient's response to treatment, cause of hypoglycemia, comorbid conditions, and social situation. Most insulin reactions respond rapidly. Patients can be discharged with instructions to continue carbohydrate intake and monitor their glucose. Patients with hypoglycemia due to the sulfonylureas or long acting insulins should be admitted due to the risk of rebound from these agents. See Table 129-1 for admission guidelines.

Table 129-1

Disposition/Guidelines for Hospital Admission

View Table||Download (.pdf)
Table 129-1

Disposition/Guidelines for Hospital Admission
Inpatient care for type 2 diabetes mellitus is generally appropriate for the following clinical situations:

  • Life-threatening metabolic decompensation such as diabetic ketoacidosis or hyperglycemic hyperosmolar nonketotic state

  • Severe chronic complications of diabetes, acute comorbidities, or inadequate social situation

  • Hyperglycemia (>400 mg/dL [>22 mmol/L]) associated with severe volume depletion or refractory to appropriate interventions

  • Hypoglycemia with neuroglycopenia (altered level of consciousness, altered behavior, coma, seizure) that does not rapidly resolve with correction of hypoglycemia

  • Hypoglycemia resulting from long-acting oral hypoglycemic agents

  • Fever without an obvious source in patients with poorly controlled diabetes

DIABETIC KETOACIDOSIS

Diabetic ketoacidosis (DKA) results from a relative insulin deficiency and counter-regulatory hormone excess causing hyperglycemia and ketonemia. Table 129-2 lists important causes.

Table 129-2

Important Causes of Diabetic Ketoacidosis

View Table||Download (.pdf)
Table 129-2

Important Causes of ...

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.

This site uses cookies to provide, maintain and improve your experience. MH Privacy Center Close