What is the workup and management for hyperglycemia (elevated blood glucose) vs hypoglycemia (low blood glucose) in the Emergency Department (ED)?

Workup and Management for Hyperglycemia vs Hypoglycemia in the ED

Hypoglycemia Management

For hypoglycemia (blood glucose <70 mg/dL), immediate treatment is required with oral glucose (15-20g) for conscious patients or parenteral glucose/glucagon for unconscious patients, as hypoglycemia is a medical emergency associated with significant morbidity and mortality. 1

Initial Assessment

• Check blood glucose immediately in any patient with altered mental status, agitation, diaphoresis, confusion, seizures, or coma 1
• Document blood glucose level before treatment when possible 1
• Identify risk factors: insulin therapy, sulfonylurea use, decreased oral intake, alcohol use 1

Treatment Algorithm

1. Conscious patient able to swallow:

   • Administer 15-20g oral glucose (glucose tablets, juice, or glucose-containing food)
   • Recheck blood glucose after 15 minutes
   • Repeat treatment until blood glucose >70 mg/dL 1

2. Unconscious patient or unable to swallow:

   • Administer glucagon:
     • Adults and children >25kg: 1mg IM/SC (upper arm, thigh, or buttocks)
     • Children <25kg: 0.5mg IM/SC
     • May repeat dose after 15 minutes if no response 2
   • OR administer IV glucose (D50W) if IV access available
   • Call for emergency assistance immediately after administration 2
   • Once patient is conscious, provide oral carbohydrates to prevent recurrence 2

3. Post-treatment:

   • Monitor blood glucose every 15-30 minutes until stable
   • Review and modify insulin/medication regimen to prevent recurrence 3
   • Investigate cause of hypoglycemia

Hyperglycemia Management

Initial Assessment

• Check blood glucose, vital signs, mental status
• Assess for signs of dehydration, acidosis (Kussmaul breathing)
• Evaluate for precipitating factors: infection, medication non-adherence, new-onset diabetes 1
• Laboratory evaluation: electrolytes, renal function, urinalysis (ketones), arterial blood gas if DKA suspected 1

Diagnostic Criteria

1. Diabetic Ketoacidosis (DKA):

   • Hyperglycemia (typically >250 mg/dL)
   • Metabolic acidosis (pH <7.3, bicarbonate <18 mEq/L)
   • Ketosis (elevated serum/urine ketones) 1

2. Hyperosmolar Hyperglycemic State (HHS):

   • Severe hyperglycemia (typically >600 mg/dL)
   • Hyperosmolality (>320 mOsm/kg)
   • Absence of significant ketoacidosis
   • Often associated with altered mental status 1

Treatment Algorithm for Hyperglycemia

1. Mild to Moderate Hyperglycemia (<300 mg/dL) without DKA/HHS:

   • For patients with known diabetes: administer correction insulin dose
   • Start basal-bolus insulin regimen (0.2-0.3 units/kg/day)
   • Distribute as 50% basal insulin and 50% prandial insulin 3
   • Monitor blood glucose before meals or every 4-6 hours 3

2. Severe Hyperglycemia (>300 mg/dL) without DKA/HHS:

   • Start basal-bolus insulin regimen (0.3-0.5 units/kg/day)
   • Distribute as 50% basal insulin and 50% prandial insulin 3
   • Monitor blood glucose every 2-4 hours until stable

3. DKA or HHS Management:

   • Aggressive IV fluid resuscitation (0.9% saline at 15-20 mL/kg/hr initially)
   • Continuous IV insulin infusion (0.1 units/kg/hr) 3
   • Potassium replacement if serum potassium is <5.3 mEq/L
   • Monitor blood glucose every 1-2 hours
   • Monitor electrolytes every 2-4 hours
   • Transition to subcutaneous insulin when:
     • DKA: Anion gap normalizes, pH >7.3
     • HHS: Patient is hemodynamically stable with improving mental status 1

Special Considerations

Pitfalls to Avoid

• Using sliding scale insulin as sole treatment strategy for hyperglycemia (ineffective compared to basal-bolus regimens) 3
• Discontinuing basal insulin in patients with type 1 diabetes (risk of DKA) 3
• Failing to identify and treat underlying precipitating factors 1
• Inadequate fluid resuscitation in DKA/HHS 1
• Overlooking hypoglycemia in patients with altered mental status 1
• Premature discharge without adequate follow-up plan 3

High-Risk Scenarios

• Pregnant patients may present with euglycemic DKA (glucose <200 mg/dL) 1
• Patients on SGLT2 inhibitors are at risk for euglycemic DKA 1
• Elderly patients with HHS have significantly higher mortality (up to 10 times higher than DKA) 4
• Patients with recurrent DKA require intensive education and close follow-up 1

Disposition

• Mild hyperglycemia without complications: may discharge with follow-up
• DKA/HHS: admit to appropriate level of care (ICU if severe)
• Hypoglycemia: may discharge after resolution if cause identified and addressed, with clear follow-up plan
• Consider admission for severe or recurrent hypoglycemia, especially in elderly or those with comorbidities 1

By following these evidence-based protocols for the management of hyperglycemia and hypoglycemia in the ED, clinicians can effectively treat these potentially life-threatening conditions and improve patient outcomes.