What precautions and initial management should be taken for a diabetic patient presenting to the emergency department?

Emergency Department Management of Diabetic Patients

For diabetic patients presenting to the emergency department, immediately assess for life-threatening hypoglycemia or hyperglycemic emergencies (DKA/HHS), measure capillary blood glucose on arrival, and establish IV access while determining the precipitating cause. 1

Initial Assessment and Triage

Immediate Vital Signs and Mental Status

• Assess level of consciousness first—confusion, lethargy, or altered mental status indicates severe metabolic derangement requiring immediate intervention. 2
• Measure capillary blood glucose immediately upon ED arrival; target range is 5-10 mmol/L (90-180 mg/dL). 1
• Check for signs of severe dehydration (poor skin turgor, dry mucous membranes, hypotension, tachycardia). 3, 4

Critical Red Flags Requiring Immediate Action

• If the patient is unconscious, seizing, or unable to follow commands or swallow safely, call for advanced resuscitation support immediately. 1
• Blood glucose >16.5 mmol/L (>300 mg/dL) with altered mental status suggests DKA or HHS—obtain arterial blood gas, electrolytes, and ketone levels urgently. 1
• Kussmaul respirations (deep, labored breathing) indicate severe metabolic acidosis from DKA. 3, 4

Management of Hypoglycemia

Conscious Patient Who Can Swallow

• Administer glucose tablets immediately if available—these provide more rapid clinical relief than dietary sugars like juice or candy. 1
• If glucose tablets unavailable, give 15 grams of fast-acting carbohydrate (4 oz orange juice, 3-4 glucose tablets, or 2-4 packets of sugar). 1, 5
• Wait 10-15 minutes before re-treating; symptoms may not resolve immediately, and premature re-dosing causes rebound hyperglycemia. 1
• Recheck blood glucose after 15 minutes; if still <3.3 mmol/L (60 mg/dL) or symptoms persist, repeat treatment. 5

Unconscious or Seizing Patient

• Never attempt oral glucose in patients with altered consciousness—this causes aspiration. 2
• Establish IV access and administer dextrose 50% (D50W) 25-50 mL IV push, or consider glucagon 1 mg IM if IV access delayed. 3
• Monitor continuously; severe hypoglycemia may require dextrose infusion (D10W at 100 mL/hr) to maintain glucose >5 mmol/L. 3

Management of Hyperglycemic Emergencies (DKA/HHS)

Do NOT Attempt These Interventions Before Hospital Arrival

• Never administer insulin (any route) in the pre-hospital or initial ED setting without concurrent IV fluids and electrolyte monitoring—insulin without fluids precipitates life-threatening hypokalemia. 2
• Never give oral fluids to patients with altered mental status; only offer small sips if fully conscious and able to swallow safely. 2
• Never give oral glucose or sugary drinks to hyperglycemic patients—this worsens the metabolic crisis. 2

Fluid Resuscitation (First Priority)

• Begin aggressive IV fluid resuscitation immediately: 15-20 mL/kg/hour (typically 1-1.5 L) of 0.9% normal saline in the first hour. 2, 4
• Total fluid deficit may approach 9 liters over 24 hours; continue isotonic saline at 250-500 mL/hr after initial bolus. 2, 4
• Switch to 0.45% saline when corrected sodium is normal or elevated, and add dextrose (D5W) when glucose falls to 11-14 mmol/L (200-250 mg/dL). 1, 4

Insulin Therapy (Second Priority)

• Continuous IV insulin infusion at 0.1 units/kg/hour is the standard of care for severe DKA/HHS; do NOT use subcutaneous insulin initially. 1, 2
• For mild-moderate DKA (pH 7.0-7.3, alert patient), subcutaneous rapid-acting insulin analogs every 1-2 hours may be used with aggressive fluid management. 1, 4
• Check blood glucose hourly; adjust insulin to decrease glucose by 50-75 mg/dL per hour (2.8-4.2 mmol/L/hr). 2, 4

Electrolyte Management (Critical)

• Potassium must be monitored and replaced aggressively (20-40 mEq/L in IV fluids)—insulin drives potassium intracellularly, causing fatal cardiac arrhythmias if untreated. 2, 4
• Do NOT start insulin if serum potassium <3.3 mEq/L; replace potassium first to avoid cardiac arrest. 1, 4
• Recheck electrolytes, pH, and glucose every 2-4 hours until stable. 2, 4

Ketone Monitoring

• Patients with ketonemia ≥1.5 mmol/L or ketonuria 2+ require ICU admission for continuous monitoring. 1, 2
• Resolution of DKA requires closure of anion gap AND ketone clearance, not just glucose normalization. 1, 4

Identifying Precipitating Causes

Common Triggers to Investigate

• Infection is the most common precipitant—obtain urinalysis, chest X-ray, and blood cultures if febrile or septic appearing. 3, 4
• Myocardial infarction or stroke (especially in older adults)—obtain ECG and troponin if chest pain or neurologic symptoms present. 3, 4
• Medication non-compliance or insulin pump failure (Type 1 diabetes). 1, 4
• New-onset diabetes (25-30% of DKA cases occur in previously undiagnosed patients). 3, 4

Transition from IV to Subcutaneous Insulin

Critical Timing to Prevent Rebound Ketoacidosis

• Administer basal insulin (glargine or detemir) 2-4 hours BEFORE stopping IV insulin infusion—failure to overlap causes immediate ketoacidosis recurrence in Type 1 diabetes. 1, 5
• Calculate subcutaneous dose as half the total IV insulin given in the last 24 hours: give half as basal insulin once daily, divide remaining third into three pre-meal rapid-acting doses. 1
• For insulin pump users with Type 1 diabetes, restart pump immediately when discontinuing IV insulin. 5

Disposition and Follow-Up

Admission Criteria

• All patients with severe DKA (pH <7.0, altered mental status, ketonemia ≥1.5 mmol/L) require ICU admission. 1, 2
• Patients with blood glucose >16.5 mmol/L (300 mg/dL) despite treatment, or inability to tolerate oral intake, require hospital admission. 1
• Older adults (≥80 years) on insulin or sulfonylureas with hypoglycemia should be admitted due to high recurrence risk. 1

Discharge Planning for Stable Patients

• Ensure blood glucose is 5-10 mmol/L (90-180 mg/dL) and patient can tolerate oral intake before discharge. 1, 5
• Provide glucose meter, test strips, insulin supplies, and written instructions with specific medication names, doses, and timing. 5
• Schedule follow-up within 1 month for HbA1c <8%, within 1-2 weeks for HbA1c 8-9%, or arrange urgent diabetologist consultation for HbA1c >9%. 1, 5
• Educate on hypoglycemia recognition and treatment (15 grams fast-acting carbohydrate for glucose <3.3 mmol/L), sick-day management, and when to return to ED. 5

Common Pitfalls to Avoid

• Never discharge Type 1 diabetes patients on sliding-scale insulin alone without scheduled basal insulin—this guarantees DKA recurrence. 5
• Do not use bicarbonate routinely in DKA; it provides no mortality benefit and may worsen hypokalemia. 1
• Avoid over-aggressive insulin dosing; rapid glucose correction causes cerebral edema (especially in children) and hypokalemia. 4
• Patients with recurrent ED visits for hyperglycemia (32.5% within 30 days) benefit from specialized diabetes clinic follow-up, which reduces readmissions by 70%. 6