This document provides guidance on assessing and managing diabetic emergencies in remote clinics. It outlines the signs and symptoms of three potential emergencies: diabetic ketoacidosis (DKA), hyperosmolar nonketotic hyperglycemia (HONK), and hypoglycemia. For DKA and HONK, it describes the diagnostic criteria and management approach, including fluid resuscitation and monitoring. Hypoglycemia treatment focuses on oral carbohydrate intake or glucagon and dextrose injections. The document aims to equip remote nurses to initially recognize and stabilize patients until transfer to a hospital.

1. Diabetic Emergencies
How to assess and manage a patient presenting with a
potential diabetic emergency in a remote area clinic

2. Competency & Policies
 Competency
 JHAH MSP

3. 3 Potential Emergencies
 Diabetic Ketoacidosis (DKA)
 Hyperosmolar Non Ketotic (HONK) Hyperglycaemia
 Hypoglycaemia

4. Objectives
To provide the remote clinic nurse with an overview of potential
patient signs and symptoms and their management

5. Case Study
 23 year old office worker, known diabetic type 1
 Brought in by his colleague as he had been sick
 Recently received bad news from family in Manila
 Has been vomiting all night
 He had been in Bahrain drinking alcohol with a family friend
yesterday to “cheer himself up”

6. What next?

7. Start as always with the …
 ABC of resuscitation
 History + examination
 Pregnancy check?
 Blood tests – FBC, U+E, LFTs, CRP, amylase if available
 Blood glucose
 Arterial blood gas (not available in RACs)
 Urinary ketones

8. Assessment Results
 A - patent
 B - 29 breaths per minute, rapid shallow breaths, 100% on air
 C – BP 102/68. Pulse 107. Cap refill 7 sec
 History – as above
 Examination – slightly tender abdomen
 Bloods taken
 Peripheral blood glucose 160 mg/dL
 Urinary ketones +ve

9. Impression?

10. Possible Diagnoses
 Diabetes Ketoacidosis
 pH, blood glucose (serum), ketones
 Metabolic acidosis – other causes
 Sepsis, poisoning
 Pancreatitis
 Gastroenteritis

11. Diabetic Ketoacidosis (DKA)

12. Possible Indicators
 Hallmark of type 1 diabetes (insulin insufficiency)
 Previously undiagnosed DM (about 25 – 30%)
 Interruption to normal insulin regime
 Concurrent illness - usually infection

13. Signs and Symptoms
 Nausea
 Vomiting
 Abdominal pain
 Often preceding polyuria, polydipsia, weight loss
 Drowsiness/confusion/coma (severe)
 Kussmaul respiration - hyperventilation
 ‘Pear drops’ breath
 Sign of associated systemic illness (MI, infection, etc)

14. Causes of Hyperglycaemia
Type 2 Diabetes
Muscle ‘burns’ fat producing ketones

15. Forming an Impression
DKA requires all 3 of the following:
 High blood sugar
 Glucose > 200 mg/dLl
 (Finger-prick blood glucose can be normal)
• Ketones (blood or urine ≥ +++)
 Acidosis (pH<7.30 or HCO3<15mmol)

16. Management
 Consult
 ABC – if impaired
 Replace fluids
 Monitor fluid balance (I/O chart)
 Resolution of ketonaemia / insulin
 Take care: electrolytes imbalance
 Close monitoring
 Transfer

17. Fluid Replacement
Initial management: 1 L 0.9% NaCl
Consult but expect:
 30 mins (NB Age or
comorbidity)
 1hr
 2hr
 4 hr
 Then continue NaCl 0.9% as
dictated by fluid status
Subsequent management
 In hospital
 May include 10% Dextrose in
addition to 0.9% NaCl
 Sliding scale insulin
 Electrolyte replacement

18. Consider
• Absence of fever doesn’t mean absence of infection
• Alternative cause for acidosis if glucose and acidosis markedly
out of proportion
• Non specific abdominal does not mean DKA
 Patients with frequent episodes are at increased risk of dying
and diabetic complications

19. Hyper-Osmolar Non-Ketotic (HONK)
Hyperglycaemic Syndrome (HHS)
Hallmark of type 2 DM
 May occur in:
 Newly diagnosed
 Poor compliance with treatment
 Concurrent illness – especially MI, Infection, CVA
 Drugs – Steroids
 Sugary drinks

20. Cause and consequences
 Insulin production markedly reduced nut not absent
 No switch to fat metabolism
 No ketones or acidosis
 Loss of intravascular volume
 Mortality higher than DKA
 Comorbidities
 Longer diagnosis time, Electrolyte imbalance
 Cerebral oedema and PE more common

21. Presentation & Outcome
 Possibly osmotic symptoms
 Dehydration around 10L deficit
 Decreased level of consciousness
 Signs of underlying infection in up to 50%
 +/- thrombo-embolism in up to 30%
 2/3 cases previously undiagnosed
 As high as 50% mortality

22. Recognition
Diagnosis requires ALL of the following:
 Raised blood glucose (usually >500 mg/dL)
 Absence of ketones (or + or ++ only)
 Serum osmolality >350mmol

23. Management
 Consult
 Fluid replacement
 Electrolyte replacement
 Caution:
pseudohyponatraemia
 Insulin Search for cause
 Anticoagulation
 Monitor
 Transfer
1 L 0.9% NaCl
 1 hr
 2 hr
 4 hr
 8 hr
 Then continue NaCl 0.9%
as dictated by fluid status

24. Hypoglycaemia
 The Hypo-kit

25. Signs and Symptoms
Blood sugar < 70 mg/dL
 Autonomic:
 Sweating, palpitations, tremor, hunger
 Neuroglycopenic
 Confusion, clumsiness, behavioural changes, seizures
 Non-specific
 Nausea, headache, tiredness

26. Causes
 Drug Induced
 Insulin,
 Sulphonylureas
 Alcohol
 Reactive Hypoglycaemia
 Post prandial
 Gastric surgery

27. Treatment
 If able to eat
 Glucose: Hypokit. Sweet fruit juice & lollipop
 Long acting carbohydrate eg toast/ sandwich
 In the community:
 1mg glucagon IM and long acting carbohydrate on recovery
 Hospital options-
 IM glucagon 1mg
 IV 20ml of 50% dextrose
 Other: hypostop

28. Summary
 Diabetic ketoacidosis.
 Management of diabetic ketoacidosis.
 Recognise and manage HONK (HHS)
 Recognise and manage hypoglycaemia.

29. References
 Hariman, C. (2011) Diabetic Emergencies [Online]. Available at:
https://www.mededcoventry.com/.../Diabetes%20lecture%202011%20-%... Accessed on: 28th July 2015