How to manage a patient with hyperglycemia and seizures without DKA symptoms?

Management of Hyperglycemia with Seizures in the Absence of DKA Symptoms

Patients with hyperglycemia and seizures without fruity breath or Kussmaul breathing should be treated for non-ketotic hyperglycemia (NKH) with immediate insulin therapy and fluid resuscitation, as seizures may be the first manifestation of severe hyperglycemia even without classic DKA symptoms. 1

Initial Assessment and Diagnosis

When evaluating a patient with hyperglycemia and seizures without classic DKA symptoms:

1. Check blood glucose levels immediately

   • Consider hyperosmolar hyperglycemic state (HHS) if glucose ≥600 mg/dL 2
   • Obtain venous pH, bicarbonate, and check for ketones to rule out DKA

2. Assess for other causes of seizures

   • Obtain electrolytes (particularly sodium, calcium)
   • Consider neuroimaging if focal seizures are present
   • Check for signs of infection which may precipitate both hyperglycemia and seizures

Treatment Algorithm

1. Fluid Resuscitation

• Begin with isotonic saline (0.9% NaCl) at 15-20 mL/kg/hr to expand intravascular volume and restore renal perfusion 2
• Aim to correct estimated fluid deficits within 24 hours
• Monitor vital signs, neurological status, and fluid input/output hourly

2. Insulin Therapy

• Initiate IV insulin therapy after confirming potassium is not low (K+ >3.3 mEq/L)
• Give IV bolus of regular insulin at 0.15 U/kg body weight
• Follow with continuous infusion at 0.1 U/kg/hr (approximately 5-7 U/hr in adults) 2
• Monitor blood glucose hourly and adjust insulin rate accordingly

3. Electrolyte Management

• Add potassium (20-30 mEq/L) to IV fluids once urine output is established and serum potassium is <5.0 mEq/L
• Use 2/3 KCl and 1/3 KPO₄ for replacement 2
• Monitor electrolytes every 2-4 hours

4. Seizure Management

• Seizures in hyperglycemia often resolve with correction of blood glucose 1, 3
• If seizures persist despite glucose correction, consider adding an anti-epileptic drug
• Document seizure characteristics (focal vs. generalized, duration, post-ictal state)

Special Considerations

Non-Ketotic Hyperglycemia-Related Seizures

• Seizures may be the first manifestation of hyperglycemia, particularly in NKH 1
• These can present as complex partial seizures, occipital seizures with visual symptoms, or movement-induced focal seizures 3, 4
• Unlike typical seizure disorders, these seizures may be refractory to anti-epileptic drugs but respond to glucose correction 1

Monitoring for Resolution

• Continue monitoring until:
  • Blood glucose <200 mg/dL
  • Mental status improves
  • Seizures resolve
  • Electrolyte abnormalities correct

Pitfalls and Caveats

1. Don't assume DKA is absent just because classic symptoms are missing

   • Some patients may have DKA without fruity breath or Kussmaul breathing
   • Always check laboratory values (pH, bicarbonate, ketones) 2

2. Watch for hypoglycemia during treatment

   • Insulin therapy can cause rapid drops in blood glucose
   • Symptoms include sweating, drowsiness, dizziness, anxiety, tremor, and can progress to seizures and unconsciousness 5

3. Consider underlying causes

   • Undiagnosed diabetes
   • Medication non-adherence
   • Infection
   • Stroke or other neurological conditions that may present with both seizures and stress hyperglycemia

4. Beware of hypokalemia

   • Insulin drives potassium into cells, potentially causing dangerous hypokalemia
   • Monitor potassium levels closely and replace as needed 2, 5

5. Consider rare metabolic disorders

   • In patients with unusual presentations or poor response to standard treatment, consider organic acidemias or other metabolic disorders 6

By following this approach, hyperglycemia-induced seizures typically resolve with correction of the metabolic abnormality, and long-term antiepileptic therapy may not be necessary if the underlying hyperglycemia is properly managed 1, 3.