What blood glucose level requires emergency treatment?

From the Guidelines

Blood glucose levels above 250-300 mg/dL (13.9-16.7 mmol/L) with symptoms of hyperglycemia or below 54 mg/dL (3.0 mmol/L) for severe hypoglycemia require emergency treatment. For severe hypoglycemia, immediate treatment with 15-20 grams of fast-acting carbohydrates like glucose tablets, juice, or regular soda is needed, followed by a protein-containing snack once levels stabilize 1. If the person is unconscious or unable to swallow safely, emergency services should be called immediately, and glucagon may be administered (1 mg injected subcutaneously or intramuscularly, or nasal glucagon) 1. For severe hyperglycemia, especially with symptoms like confusion, extreme thirst, fruity breath, or rapid breathing, emergency medical attention is required as this could indicate diabetic ketoacidosis or hyperosmolar hyperglycemic state, which require IV fluids, insulin, and electrolyte management in a hospital setting 1. The urgency stems from the fact that both extreme glucose levels can rapidly lead to seizures, coma, or death if not promptly addressed 1. Key symptoms that necessitate emergency medical care include ketosis, vomiting, or alteration in the level of consciousness, which may require temporary adjustment of the treatment regimen and immediate interaction with the diabetes care team 1. Adequate fluid and caloric intake must be assured, and infection or dehydration is more likely to necessitate hospitalization of individuals with diabetes versus those without diabetes 1. It is crucial to note that the most recent guidelines recommend a threshold of no greater than 180 mg/dL (10 mmol/L) for initiating insulin therapy in critically ill patients, with a recommended glucose range of 140–180 mg/dL (7.8–10 mmol/L) once insulin therapy is started 1. However, the highest quality and most recent study 1 prioritizes the management of severe hyperglycemia and hypoglycemia, emphasizing the need for emergency treatment in these cases. Therefore, emergency treatment is warranted for blood glucose levels above 250-300 mg/dL (13.9-16.7 mmol/L) with symptoms of hyperglycemia or below 54 mg/dL (3.0 mmol/L) for severe hypoglycemia.

Some key points to consider in the management of hyperglycemia and hypoglycemia include:

• Frequent monitoring of blood glucose and ketone levels in ketosis-prone patients 1
• Temporary adjustment of the treatment regimen and immediate interaction with the diabetes care team in cases of marked hyperglycemia 1
• Ensuring adequate fluid and caloric intake 1
• Hospitalization for individuals with diabetes who experience infection or dehydration 1
• Initiation of insulin therapy in critically ill patients with a threshold of no greater than 180 mg/dL (10 mmol/L) 1

From the Research

Blood Glucose Levels Requiring Emergency Treatment

• Hyperglycemic hyperosmolar state is a life-threatening complication of diabetes mellitus that requires emergency treatment, characterized by an elevated glucose level, elevated serum osmolality, minimal or absent ketones, and a neurologic abnormality, most commonly altered mental status 2.
• Diabetic ketoacidosis (DKA) is a hyperglycemic emergency that presents commonly to the emergency department, with severe DKA having the potential for significant morbidity and mortality if not recognized early and treated appropriately 3.
• The severity of DKA is classified based on the level of acidosis present rather than absolute glucose level, and treatment involves assessing and treating the inciting event, fluid hydration, insulin, and potassium repletion 3.
• Hyperglycemic hyperosmolar nonketotic coma is a severe and potentially life-threatening complication of diabetes mellitus that requires prompt diagnostics and treatment, characterized by absolute or relative insulin insufficiency and severe dehydration 4.

Glucose Levels Indicating Emergency Treatment

• A random plasma glucose ≥ 200 mg/dL (11.1 mmol/L) and symptoms of hyperglycemia can indicate a new diagnosis of type 2 diabetes, and treatment may begin in the emergency department 5.
• A glucose level greater than or equal to 400 mg/dL can indicate moderate to severe hyperglycemia, and patients with this condition may require emergency treatment 6.
• However, the importance of glucose reduction in the emergency department is unknown, and discharge glucose has not been associated with short-term adverse outcomes in patients with moderate to severe hyperglycemia 6.