Hypoglycemia and Hyperglycemia: OPD & ER Management Guidelines

PART 1 - HYPOGLYCEMIA

Definition & Classification

Symptoms

OPD/ER Management - "Rule of 15"

• Give 15-20 g fast-acting carbohydrate orally:
  • 150-200 mL fruit juice or glucose drink
  • 3-4 glucose tablets
  • 1 tablespoon sugar dissolved in water
• Recheck glucose in 15 minutes
• If BG still <72 mg/dL (4.0 mmol/L), repeat oral carbohydrate up to 3 times
• After recovery, give a long-acting carbohydrate snack (bread, biscuit) to prevent rebound

• Squeeze 2 tubes of 40% dextrose gel between gum and cheek (buccal absorption)
• Consider intranasal glucagon (new formulation - now available and safe)
• If no IV access available: Glucagon 1 mg IM or SC (thigh or deltoid)

• IV Dextrose 50% (D50W) - 25-50 mL IV push (= 12.5-25 g dextrose)
• Alternatively: Glucagon 1 mg IM if IV access delayed
• Monitor glucose every 15-30 minutes after treatment
• Basic life support if needed
• Admit for observation if: sulfonylurea-induced (prolonged action), insulin overdose, recurrent episodes, or unexplained cause

• Dextrose alone may cause paradoxical rebound hypoglycemia (stimulates more insulin release)
• Add Octreotide 50-100 mcg SC after 1st or 2nd recurrent episode to suppress insulin secretion
• Serial injections every 6-8 hours or constant IV infusion 125 mcg/h may be needed
• These patients often require 24-hour observation

• Identify and address the cause: missed meals, excess insulin/sulfonylurea dose, alcohol, exercise
• Adjust medication doses
• Educate patient and family on recognition and "Rule of 15"
• Screen for hypoglycemia unawareness (needs lower glycemic targets, CGM consideration)
• Nocturnal hypoglycemia prevention: bedtime cornstarch snack, switch to ultra-long-acting insulins (glargine U300, degludec)

PART 2 - HYPERGLYCEMIA: DKA and HHS

Diagnostic Criteria

• Glucose typically >600 mg/dL (often >800-1000 mg/dL)
• Serum osmolarity >320 mOsm/kg
• pH >7.30, HCO3 >18 (minimal ketosis, though some overlap with DKA exists)
• Altered sensorium correlates with severity of hyperosmolarity
• Occurs mainly in elderly type 2 diabetics

Initial ER Workup

• Bedside glucose (rapid)
• Venous blood gas (pH - venous pH ~0.03 lower than arterial; arterial BGA usually not needed)
• Serum electrolytes (Na, K, Cl, HCO3)
• Anion gap = Na - (Cl + HCO3) - normal 8-12
• BUN, creatinine (prerenal azotemia expected)
• Beta-hydroxybutyrate (quantitative - >3 mmol/L confirms DKA; more reliable than urine dipstick ketones which only detect acetoacetate)
• CBC (leukocytosis - may be from acidosis alone; WBC >25,000 or fever suggests infection)
• Serum phosphate, magnesium, calcium
• ECG (assess for hyperkalemia/hypokalemia, and rule out MI as precipitant)
• Urinalysis + urine ketones
• Blood cultures, CXR if infection suspected
• Corrected sodium = measured Na + 2.4 × [(glucose - 100)/100]

DKA Management (ER)

1. IV Fluids (Highest Priority - Start Immediately)

• 0.9% Normal Saline (NS) 1 L in first hour (resuscitation)
• Continue at 250-500 mL/h based on hydration status
• Typical total deficit: 3-6 L
• When glucose falls to ≤250 mg/dL: add 10% Dextrose to the NS - do NOT stop insulin; this "dual bag" approach allows continued insulin infusion to clear ketones
• Switch to 0.45% NS once patient is euvolemic to avoid hyperchloremic acidosis

2. Potassium Replacement (Do Before or With Insulin If K+ Low)

• Monitor K+ every 2 hours during first phase
• Target K+ 4.0-5.0 mEq/L
• Cardiac monitoring recommended for severe hypokalemia
• Oral K+ is preferred as soon as tolerated
• Typical total K+ replacement in first 24h: 100-200 mEq

3. Insulin

• Start only after K+ ≥3.5 mEq/L is confirmed
• Regular insulin IV infusion at 0.1-0.14 units/kg/h (no bolus needed in most patients)
• Alternatively: 0.1 unit/kg IV bolus then 0.1 unit/kg/h infusion
• Target glucose drop: 50-75 mg/dL/h
• If glucose not dropping after 1 hour: check IV line, then increase rate
• When glucose ≤250 mg/dL AND pH >7.3 AND HCO3 ≥18: reduce insulin to 0.05 units/kg/h, add dextrose to IV fluid
• Resolution criteria: glucose <200, HCO3 ≥15, venous pH >7.3, anion gap closed
• Transition to subcutaneous insulin: Overlap SC insulin with IV infusion by 1-2 hours before stopping infusion (prevents rebound ketosis)
• Continue background long-acting SC insulin throughout treatment if patient was already on it

4. Bicarbonate

• Not routinely recommended - risk of paradoxical CNS acidosis and worsening hypokalemia
• Consider only if pH <7.0 and patient not responding to fluids + insulin
• If given: 100 mEq NaHCO3 in 400 mL sterile water + 20 mEq KCl over 2 hours

HHS Management (ER)

• Fluids are the primary treatment - more aggressive replacement needed than DKA (deficit 8-10 L)
• 0.9% NS 1 L/h for first 2-4 hours, then reassess
• Switch to 0.45% NS once hemodynamically stable (to reduce osmolarity gradually)
• Goal: reduce osmolarity by no more than 3-8 mOsm/kg/h to prevent cerebral edema
• Insulin: Start at 0.05 units/kg/h (lower than DKA) - fluids alone will often lower glucose initially; start insulin when glucose stops falling with fluids alone
• Potassium replacement same as DKA
• Glucose target: 250-300 mg/dL initially (do not drop too fast)
• Thromboprophylaxis should be considered - elderly HHS patients are high risk for DVT/stroke

• Reduce osmolality slowly
• Avoid large volumes of hypotonic fluids
• Do not allow serum Na+ to fall during treatment
• Avoid unnecessary bicarbonate
• Avoid hypoxia, hypokalemia, hypophosphatemia

Criteria for ICU vs. Floor Admission

• Patients presenting early who tolerate oral fluids may be managed in ER/observation and discharged after 6-12 hours of therapy

Discharge/OPD Follow-Up After Hyperglycemic Crisis

• Identify and address precipitant
• Restart or optimize insulin regimen before discharge
• Educate: sick-day rules (never stop insulin during illness, monitor more frequently)
• Recurrent DKA: address access barriers, insulin storage, psychosocial factors, consider CGM
• OPD follow-up within 1-2 weeks
• Review HbA1c and adjust long-term management

Quick Reference Summary Card

HYPOGLYCEMIA
BG ≤70 mg/dL
Conscious → 15g carbs PO → recheck 15 min → repeat x3
Unconscious → D50W 25-50 mL IV OR Glucagon 1 mg IM
Sulfonylurea → add Octreotide 50 mcg SC, observe 24h

DKA (Glucose >250 + Ketones + pH <7.3)
1. NS 1 L/h IVF → switch to D10+NS when BG ≤250
2. K+ check → hold insulin if K+ <3.3; replace to ≥3.5 first
3. Insulin: 0.1 unit/kg/h IV → reduce when BG ≤250
4. Bicarb: ONLY if pH <7.0
5. Overlap SC insulin 1-2h before stopping infusion

HHS (Glucose >600 + Osmolarity >320)
1. Aggressive IVF (8-10 L deficit) - NS → 0.45%NS
2. Reduce osmolarity slowly (<3-8 mOsm/kg/h)
3. Insulin 0.05 unit/kg/h after BG plateaus
4. Thromboprophylaxis in elderly

• Goldman-Cecil Medicine, 26th Ed. - Chapters 210, 211 (Hypoglycemia, DKA, HHS)
• Tintinalli's Emergency Medicine, 9th Ed. - Chapters 224, 225 (Hypoglycemia ER management, DKA ER management)
• ADA Standards of Care 2025 (released Dec 2024) - updated CGM guidance, hyperglycemic crisis protocols