Hyperglycemic Emergencies

Diabetic ketoacidosis and hyperosmolar hyperglycemic state have the same cause: insufficient insulin.

There are two types of hyperglycemic emergencies: diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS). These situations require emergency medical intervention, since they can lead to serious conditions such as coma, even death, if left untreated.

Diabetic ketoacidosis and hyperosmolar hyperglycemic state have the same cause: insufficient insulin.

These complications can arise in specific situations, during sick days, for example.

Diabetic ketoacidosis

Diabetic ketoacidosis mainly occurs in people with type 1 diabetes. It is characterized by hyperglycemia often greater than 20 mmol/L, with the presence of ketones in the blood or urine.

Ketones are produced from the breakdown of fats. Their accumulation in the blood is toxic for the body. This situation arises when the body lacks insulin and must use its fat reserves for the energy it normally gets from glucose.

Diabetic ketoacidosis can arise due to a forgotten or skipped insulin dose, an improper adjustment to the insulin dose, an insulin pump that stops working, or a serious medical problem (e.g., heart attack, pneumonia).

The following symptoms are associated with diabetic ketoacidosis:

  • deep, rapid breathing
  • fruity breath (acetone odour)
  • nausea, vomiting
  • abdominal pain
  • decreased consciousness, confusion, agitation, unusual behaviour

Hyperosmolar hyperglycemic state

Hyperosmolar hyperglycemic state occurs primarily in people with type 2 diabetes. This state is characterized by hyperglycemia often greater than 30 mmol/L, and severe dehydration.

During a hyperglycemic episode, the accumulation of glucose in the blood increases the frequency and volume of urination. This can cause excessive water loss and significant dehydration. This can be followed by a drop in blood pressure leading to decreased consciousness and eventually to coma if the HHS is left untreated.

Lack of insulin is the cause. However, contrary to diabetic ketoacidosis, in HHS there is normally no significant presence of ketones in the blood or urine because insulin is not totally absent.

The symptoms are typical of hyperglycemia, including frequent and abundant urination, intense thirst and exhaustion, as well as such signs of dehydration as dry mouth, sunken eyes, dry skin, etc.

People with kidney problems are more susceptible to HHS because their kidneys are less efficient in eliminating excess glucose in the blood when hyperglycemic.

The elderly are less aware of their own thirst, so are consequently more at risk.

When to call 911?

Call a doctor without delay or get the person to Emergency if:

  • the person’s blood glucose (sugar) level is above 14 mmol/L and there are ketones present
    • in the urine: “medium” to “high” level
    • in the blood: a level higher than 1.5 mmol/L
  • for type 1 diabetes: blood glucose (sugar) level is above 20 mmol/L with nausea, vomiting and/or abdominal pain
  • for type 2 diabetes: blood glucose (sugar) level is above 25 mmol/L with excessive drowsiness
  • the person cannot retain liquids because of vomiting or diarrhea
  • the person’s state of consciousness changes; e.g., confusion, agitation, absence of reaction to stimuli, hallucinations or unusual behaviour
  • there are signs of dehydration: dry mouth, sunken eyes, dry skin, etc.
  • body temperature is above 38.5°C for more than 48 hours

Prevent hyperglycemic emergencies

In addition to the basic measures to prevent hyperglycemia , the following recommendations can help you prevent a hyperglycemic emergency.

If you have type 1 diabetes:

  • Check for ketones in your urine or blood if your blood glucose (sugar) levels are higher than 14mmol/L, and during sick days.
  • Measure your blood glucose (sugar) levels more frequently and follow the protocol established by your health care team for sick days.
  • Keep adequately hydrated if your blood glucose (sugar) level is above 14 mmol/L.

If you have type 2 diabetes:

  • Measure your blood glucose (sugar) levels more frequently and follow the recommendations of your health care team for sick days.
  • Keep adequately hydrated if your blood glucose (sugar) level is above 14 mmol/L.

 

Research and text: Diabetes Québec Team of Health Care Professionals

June 2014 (updated on June 2018)

©All rights reserved Diabetes Quebec

 

References:

Geoffroy, L. and Gonthier, M., (2012) “L’hyperglycemie et l’acidose diabétique,” Le diabète chez l’enfant et l’adolescent, 2e édition. Montréal: Éditions du CHU Ste-Justine, pp. 355-364.

J. Goguen, J. Gilbert. Diabetes Canada 2018 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada: Hyperglycemic Emergencies in Adults. Can J Diabetes 2018;42(Suppl 1):S109-S114.

CHUM-Hotel-Dieu Metabolic Medicine Day-care Centre (2013), “Hyperglycemia”, Understand Your Diabetes and Live a Healty Life, Montreal: Rogers Publishing Limited, pp. 16-19.

Info-Santé (811 hotline) hyperglycemia protocol (2011).