National Diabetes Month | Emergency Medicine
A normal reading after rescue does not make the initial event less severe.
Consider an adult with type 2 diabetes who arrives after two days of vomiting. The triage glucose is 178 mg/dL. The patient took empagliflozin yesterday, has barely eaten, and is breathing deeply even at rest. The deep respirations warrant a venous blood gas and blood ketone testing even at this glucose level.
The reverse problem occurs after treatment. An older adult who could not speak coherently at home may be answering questions by the time EMS reaches the hospital. The glucose on arrival reflects the dextrose EMS gave. It says little about the severity of the original episode or whether the medication that caused it is still active.
For November’s National Diabetes Month, this clinical review follows three decisions emergency clinicians face: when to test for diabetic ketoacidosis (DKA) despite a modest glucose elevation, how to recognize and safely correct hyperosmolar hyperglycemic state (HHS), and what to establish before a patient who has recovered from severe hypoglycemia leaves monitored care.
Medication history
When the glucose does not look like DKA
Abdominal pain, vomiting, and deep respirations can precede recognition of DKA, particularly when a patient has no previous diagnosis of diabetes. The deep breathing is compensation for metabolic acidosis. In the opening case, ask when the patient last ate, which diabetes medications they continued, and whether they reduced or omitted insulin. Obtain electrolytes, creatinine, venous pH, and blood beta-hydroxybutyrate while assessing perfusion and looking for a precipitating illness. Infection and interruption of insulin delivery are common triggers; identifying one does not exclude the other.
The 2026 ADA diagnostic criteria require three findings in adults: a history of diabetes or glucose of at least 200 mg/dL; ketosis, preferably demonstrated by blood beta-hydroxybutyrate of at least 3.0 mmol/L; and acidosis, defined by pH below 7.3, bicarbonate below 18 mmol/L, or both. Urine ketones of 2+ or greater can support the diagnosis when blood testing is unavailable. Urine strips measure acetoacetate, however, not beta-hydroxybutyrate, the predominant ketone early in DKA. A weakly positive urine result can understate how ill the patient is.
Suppose the patient with a glucose of 178 mg/dL has a venous pH of 7.24 and beta-hydroxybutyrate of 4.5 mmol/L. Their known diabetes, ketonemia, and acidemia meet the adult criteria for DKA. The FDA warning on SGLT2 inhibitors addresses precisely this diagnostic hazard: a patient taking one of these drugs can develop ketoacidosis without marked hyperglycemia. Stop the SGLT2 inhibitor and treat the DKA. Because glucose is already below 200 mg/dL, dextrose is needed from the start of insulin treatment. The insulin suppresses ketone production; the dextrose allows it to continue safely.
Adult DKA and HHS require different treatment endpoints
In HHS, fluid loss often accumulates over days. A family member may describe increasing thirst and frequent urination followed by weakness, confusion, and eventually an inability to get to water without help. Ask what the patient could do independently a week ago. A change from getting their own drinks to depending on someone to bring them water helps explain both the size of the fluid deficit and why it worsened.
In adults, HHS requires glucose of at least 600 mg/dL and hyperosmolality: calculated effective serum osmolality above 300 mOsm/kg or total osmolality above 320 mOsm/kg. Blood beta-hydroxybutyrate should be below 3.0 mmol/L, pH at least 7.3, and bicarbonate at least 15 mmol/L. Check ketones and acid-base status even when the glucose is strikingly high. A hyperosmolar patient who also meets DKA criteria has a mixed crisis. That patient needs insulin to suppress ketogenesis as well as controlled correction of hyperosmolality.
Start by restoring perfusion. Both isotonic saline and balanced crystalloids are accepted initial fluids in adults. In a subgroup analysis of two randomized trials, adults with DKA who received balanced crystalloids reached resolution at a median of 13.0 hours, compared with 16.9 hours with saline. This was a subgroup of 172 adults with DKA, not evidence that every patient with HHS should receive the same fluid or volume. In an older adult with heart failure or advanced kidney disease, give smaller boluses and reassess perfusion and signs of congestion before repeating them.
Before starting insulin, check potassium. Osmotic diuresis can leave a patient potassium-depleted even when the initial serum value is normal or high. Insulin will shift potassium back into cells. The adult hyperglycemic crises consensus report advises replacing potassium first when it is below 3.5 mmol/L and delaying insulin until it is above 3.5 mmol/L. Recheck potassium during treatment; the admission value cannot guide the entire infusion.
Treatment endpoints
DKA: How to tell when ketosis has resolved
In DKA, glucose typically corrects before ketonemia. When glucose falls below 250 mg/dL, add dextrose and adjust the insulin infusion according to protocol rather than stopping insulin. Follow blood beta-hydroxybutyrate until it is below 0.6 mmol/L and either venous pH is at least 7.3 or bicarbonate is at least 18 mmol/L. Urine ketones can remain positive during recovery. Conversely, chloride-rich fluids can leave a patient with a low bicarbonate after ketones have cleared. Knowing which measurement remains abnormal can prevent several unnecessary hours of treatment.
HHS: How to judge the rate of correction
In HHS, follow the rate of change in osmolality alongside cognition, urine output, and perfusion. The adult consensus recommends a fall in osmolality of 3 to 8 mOsm/kg per hour. An early rise in measured sodium as glucose falls is expected and is not, by itself, a reason to switch to hypotonic fluid. At handoff, report the last two osmolality values and their collection times. A glucose value alone gives the receiving clinician no way to judge the rate of correction. HHS, severe DKA, altered mental status, or a critical precipitating illness warrants intensive care.
Pediatric assessment
Pediatric DKA and the fluid question
A child with polyuria, new bedwetting, weight loss, and vomiting may be presenting with diabetes for the first time. Ask about thirst and urination even when the presenting complaint is abdominal pain. Once DKA is recognized, use a pediatric pathway. Adult fluid volumes and insulin orders should not carry over by default.
Concern about cerebral injury has historically made clinicians cautious about rehydrating children with DKA. The PECARN DKA FLUID trial compared faster and slower rehydration using two saline concentrations across 1,389 DKA episodes in 1,255 children. Within the regimens studied, neither infusion rate nor sodium chloride concentration significantly changed neurologic outcomes. The finding supports treating hypovolemia rather than withholding indicated fluid. It does not establish that any infusion rate is safe or that neurologic checks can be relaxed.
The Canadian Paediatric Society’s pediatric DKA guidance recommends initial isotonic fluid, followed by insulin only after the first hour of fluids and once potassium is above 3.0 mmol/L. Do not give an IV insulin bolus. Document a baseline neurologic examination so the next assessment has a meaningful comparison. New headache, slowing heart rate, or declining alertness after initial improvement should raise concern for cerebral injury. Initiate the pediatric cerebral injury protocol and seek critical care support immediately; treatment should not wait for imaging.
EMS to ED
Severe hypoglycemia after the patient wakes up
For the patient treated by EMS, ask what they were able to do before rescue. Could they recognize the low glucose and treat it themselves, or did a partner have to administer glucagon because they could not swallow safely? The ADA definition of level 3 hypoglycemia is based on altered functioning that requires another person’s assistance for recovery, regardless of the measured glucose. A normal reading after rescue does not make the initial event less severe.
Treat according to the patient’s ability to swallow. For an alert adult who can swallow safely, give fast-acting carbohydrate, typically 15 g, and recheck glucose after 15 minutes. Repeat treatment if hypoglycemia persists. For a patient who cannot protect their airway, avoid oral carbohydrate; give IV dextrose if access is available or glucagon if it is not. Continue bedside glucose checks after recovery. Persistent confusion or focal findings despite corrected glucose warrant evaluation for another cause rather than repeated attribution to the original low.
Reconstruct the hours before the event with the patient, family, and EMS. Which insulin was taken, how much, and when? Did the patient eat the meal they expected to eat? Did they take a sulfonylurea such as glipizide? A missed meal after rapid-acting insulin presents a different recurrence risk from a dosing error with long-acting insulin or ongoing insulin secretion from a sulfonylurea. Reduced kidney function and a recent decline in oral intake also matter when judging whether the usual regimen is still appropriate.
With suspected sulfonylurea toxicity, dextrose corrects the immediate low but can stimulate additional insulin release. The Utah Poison Control Center’s guidance on octreotide explains its role in limiting that release. Involve a poison center or medical toxicologist to guide therapy and observation. A patient who wakes after dextrose but requires repeated doses has not demonstrated sustained recovery. Recurrent lows, an uncertain exposure, or ongoing need for IV glucose favor monitored care.
What the next clinician needs to know
An ED handoff that reads “glucose improved” leaves the next team to reconstruct the problem.
- For DKA, report the last ketone and pH or bicarbonate, the potassium trend, and whether insulin and dextrose are running. When transitioning off IV insulin, document when basal insulin was given so that coverage overlaps.
- For HHS, include the osmolality trend and whether mentation has returned to baseline.
- After hypoglycemia, report the suspected agent, the last rescue dose, and what the glucose did afterward without additional treatment.
Before discharge, ask a question that a medication list cannot answer: “Do you have the insulin, needles, and testing supplies you need for tonight?” After severe hypoglycemia, review the regimen and make sure someone who might witness another episode knows where the glucagon is and how to use it. For the patient who developed DKA while vomiting, review which medication to hold during illness, when to check ketones, and whom to call if they cannot keep fluids down. A useful outcome for National Diabetes Month is a patient who can recognize the circumstances that brought them to the ED and knows what to do before they recur.
References
- National Institute of Diabetes and Digestive and Kidney Diseases. National Diabetes Month. View source
- American Diabetes Association Professional Practice Committee for Diabetes. (2026). Diabetes care in the hospital: Standards of Care in Diabetes, 2026. Diabetes Care, 49(Suppl. 1). View source
- Umpierrez, G. E., Davis, G. M., ElSayed, N. A., et al. (2024). Hyperglycemic crises in adults with diabetes: A consensus report. Diabetes Care, 47(8), 1257-1275. View source
- U.S. Food and Drug Administration. FDA revises labels of SGLT2 inhibitors for diabetes to include warnings about too much acid in the blood and serious urinary tract infections. View source
- Self, W. H., Evans, C. S., Jenkins, C. A., et al. (2020). Clinical effects of balanced crystalloids vs saline in adults with diabetic ketoacidosis: A subgroup analysis of cluster randomized clinical trials. JAMA Network Open, 3(11), e2024596. View source
- Kuppermann, N., Ghetti, S., Schunk, J. E., et al. (2018). Clinical trial of fluid infusion rates for pediatric diabetic ketoacidosis. New England Journal of Medicine, 378, 2275-2287. View source
- Canadian Paediatric Society. Current recommendations for management of paediatric diabetic ketoacidosis. View source
- American Diabetes Association Professional Practice Committee for Diabetes. (2026). Glycemic goals, hypoglycemia, and hyperglycemic crises: Standards of Care in Diabetes, 2026. Diabetes Care, 49(Suppl. 1). View source
- Utah Poison Control Center. (2022). Fast facts: Octreotide. View source