When should a patient with hyperglycemia be sent to the Emergency Room (ER)?

From the Guidelines

You should send a patient to the emergency room for hyperglycemia when they exhibit severe symptoms, such as reduced level of consciousness, vomiting more than 4 times in 12 hours, low blood pressure, moderate or high ketones, increased heart rate, or fever, as recommended by the most recent consensus guidelines 1. When considering the management of hyperglycemia, it's crucial to prioritize the patient's symptoms and overall clinical presentation. The guidelines suggest that patients with severe symptoms, such as those mentioned above, should seek immediate medical attention.

• Key symptoms that warrant emergency room evaluation include:
  • Reduced level of consciousness or new confusion
  • Vomiting more than 4 times in 12 hours
  • Low blood pressure (SBP <80 mm Hg)
  • Moderate or high ketones (for patients taking SGLT2i or insulin)
  • Increased heart rate (increase by 30 bpm)
  • Fever (temperature >38 °C or 101 °F on 2 measurements)
• For patients with less severe symptoms, home management with supplemental insulin and increased fluid intake may be appropriate, but they should be monitored closely for any signs of deterioration. The urgency of sending a patient to the emergency room for hyperglycemia stems from the potential for severe hyperglycemia to rapidly progress to life-threatening conditions like diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS), which can cause electrolyte imbalances, cerebral edema, cardiac arrhythmias, and even death if not treated promptly with IV fluids, insulin, and electrolyte management in a hospital setting 1.

From the FDA Drug Label

Hyperglycemia (High Blood Sugar) and Diabetic Ketoacidosis (DKA) Hyperglycemia (too much glucose in the blood) may develop if your body has too little insulin Hyperglycemia can be brought about by any of the following: Omitting your insulin or taking less than your doctor has prescribed. Eating significantly more than your meal plan suggests. Developing a fever, infection, or other significant stressful situation. In patients with type 1 or insulin-dependent diabetes, prolonged hyperglycemia can result in DKA (a life-threatening emergency) The first symptoms of DKA usually come on gradually, over a period of hours or days, and include a drowsy feeling, flushed face, thirst, loss of appetite, and fruity odor on the breath. With DKA, blood and urine tests show large amounts of glucose and ketones. Heavy breathing and a rapid pulse are more severe symptoms If uncorrected, prolonged hyperglycemia or DKA can lead to nausea, vomiting, stomach pain, dehydration, loss of consciousness, or death. Therefore, it is important that you obtain medical assistance immediately.

You should send a patient to the ER for hyperglycemia if they are experiencing symptoms of Diabetic Ketoacidosis (DKA), such as:

• Drowsy feeling
• Flushed face
• Thirst
• Loss of appetite
• Fruity odor on the breath
• Heavy breathing
• Rapid pulse
• Nausea
• Vomiting
• Stomach pain
• Dehydration
• Loss of consciousness These symptoms indicate a life-threatening emergency that requires immediate medical attention 2.

From the Research

Hyperglycemia and Emergency Room Visits

• Hyperglycemia, or high blood sugar, is a serious condition that can lead to severe complications if left untreated 3, 4, 5, 6, 7.
• The decision to send a patient to the emergency room (ER) for hyperglycemia depends on various factors, including the severity of symptoms, the patient's medical history, and the presence of other health conditions.

Symptoms and Severity

• Mild hyperglycemia may not require immediate ER attention, but severe hyperglycemia can lead to life-threatening complications, such as diabetic ketoacidosis (DKA) or hyperglycemic hyperosmolar nonketotic syndrome (HHNS) 4, 6.
• Symptoms of severe hyperglycemia include:
  • High blood sugar levels (above 250 mg/dL)
  • Confusion or altered mental state
  • Severe thirst and dehydration
  • Frequent urination
  • Flushed skin
  • Rapid heartbeat
  • Fruity breath odor

Treatment and Management

• Patients with type 2 diabetes may be treated with oral medications, such as metformin, sulfonylureas, or other antihyperglycemic agents 3, 4, 5, 6, 7.
• In some cases, patients may require insulin therapy to control their blood sugar levels.
• The choice of treatment depends on various factors, including the patient's medical history, lifestyle, and personal preferences.

ER Visit Criteria

• Patients with severe hyperglycemia or those experiencing symptoms of DKA or HHNS should be sent to the ER immediately 4, 6.
• Other criteria for ER visits include:
  • Blood sugar levels above 400 mg/dL
  • Presence of ketones in the urine or blood
  • Severe dehydration or electrolyte imbalances
  • Confusion, altered mental state, or loss of consciousness
  • Severe abdominal pain or vomiting
  • Fever or signs of infection

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