Clinical Assessment

1. Hyperglycemic Crisis - Likely Diabetic Ketoacidosis (DKA) or Hyperosmolar Hyperglycemic State (HHS)

• GRBS 226 mg/dL with fatigue, multiple episodes of vomiting, and severe weakness in a known diabetic = decompensated diabetes
• At 226, this could be early/moderate DKA (glucose in DKA can range from near-normal to >1000 mg/dL)
• The vomiting itself is a hallmark of DKA - "nausea and vomiting, weakness, lethargy" are classic features (Goldman-Cecil Medicine)
• DKA can also mask the true sodium and be complicated by superimposed metabolic alkalosis from vomiting

2. Hypertensive Urgency/Emergency

• BP 150/110 mmHg in a known hypertensive, with dizziness - this is borderline hypertensive urgency
• Severe giddiness (vertigo/dizziness) with headache-level BP warrants close monitoring for hypertensive encephalopathy
• BP > 180/110 qualifies as hypertensive emergency; at 150/110, this is urgency but must be watched

3. Must Rule Out

• Hypertensive encephalopathy (if confusion/vision changes present)
• Acute ischemic stroke (new neurological symptoms + hypertension)
• Acute MI / Cardiac event (chest pain + HTN + weakness)
• Acute renal failure (DM + HTN = high risk)

Immediate Workup (ER)

Treatment Protocol

A. For Hyperglycemic Crisis (DKA)

• Normal saline (0.9% NaCl) 1 liter over the first hour
• Then 500 mL/hour for next 2-4 hours depending on volume status
• Switch to 0.45% NaCl once corrected Na normalizes
• "Restoration of circulating volume with adequate tissue perfusion is paramount. Fluid losses of 5-10 liters are common" - Goldman-Cecil Medicine

• ONLY start insulin AFTER checking potassium - if K+ < 3.5 mEq/L, correct K first before insulin
• Regular insulin IV infusion: 0.1 units/kg/hour (e.g., 50 units in 500 mL NS = 0.1 unit/mL)
• Or insulin bolus: 0.1 units/kg IV, then 0.1 units/kg/hour infusion
• Target: blood glucose drop of ~50-75 mg/dL per hour
• When glucose reaches 200-250 mg/dL, switch IV fluid to 5% dextrose + 0.45% NaCl and reduce insulin to 0.05 units/kg/hour

• If K+ 3.5-5.0: Add 20-40 mEq KCl per liter of IV fluid
• If K+ < 3.5: Give 40 mEq/hour KCl before starting insulin
• If K+ > 5.5: Hold K replacement, monitor every 2 hours

• Blood glucose every 1 hour
• Electrolytes, BUN, creatinine every 2-4 hours
• Urine output monitoring (catheterize if needed)

• Vomiting itself can precipitate DKA - treat with antiemetics
• Screen for infection (UTI, pneumonia)

B. For Hypertension (BP 150/110)

• Restart any withheld home medications
• Add or uptitrate oral agents

Note: In a hypertensive urgency (150/110), the goal is to reduce BP by no more than 25% in the first 24 hours. Do NOT normalize acutely. (Goldman-Cecil)

• Admit to ICU/HDU
• IV nicardipine 5 mg/hour or IV labetalol 20 mg slow IV bolus
• Reduce BP by 10-15% over first 1-2 hours, then another 10-15% over next 12-24 hours

C. Symptomatic Relief

Summary: Immediate Priority Order

1. IV access x2 + bloods (electrolytes, ABG, ketones)
2. 1L Normal Saline stat
3. ECG (rule out MI)
4. Check K+ before starting insulin
5. Start regular insulin infusion
6. Antiemetic IV (ondansetron)
7. Oral antihypertensive (amlodipine or ARB) - do NOT aggressively drop BP
8. Monitor vitals, glucose, urine output hourly

Clinical Note: In known DM + HTN with vomiting, fatigue, and hyperglycemia, DKA is the primary emergency driving the presentation. The hypertension is likely worsened by the metabolic stress - it may partially improve as DKA is corrected. Prioritize fluid + insulin protocol. The GRBS of 226 may underestimate the true metabolic derangement; blood gas and anion gap are essential.