In the United States approximately 34 million individuals have a diagnosis of diabetes with pre-diabetes impacting an estimated 88 million more1. At an annual cost of $327 billion dollars care related to diabetes accounts for one out of every four dollars spent on health care costs within the US2. The added strain placed on our nation’s health system throughout the COVID-19 pandemic has often resulted in patient’s delaying care, presenting at later disease stages, and requiring intervention for acute complications of conditions such as diabetes.
Diabetic ketoacidosis (DKA) is perhaps the most well recognized acute complication related to hyperglycemia, though clinicians should also learn to recognize hyperglycemic hyperosmolar state (HHS) given the relatively high associated mortality rate; 1-5% versus 20-50% respectively3-5. Both DKS and HHS can occur with either type 1 or type 2 diabetes however, DKA is more common in type 1 diabetes (accounting for two thirds of hospital presentations) and 90% of patients presenting with HHS have a diagnosis of type 2 diabetes3. Typically described as distinct conditions, clinicians should be aware that nearly one third of patients may present with findings of both4.
Initial Evaluation of Hyperglycemia
In patients presenting to the office with complaints of and/or symptoms potentially related to hyperglycemia initial evaluation should include a detailed history, physical exam, a blood glucose level, and measurement of urine or serum ketones. Initial history should seek not only to identify symptoms related to the current presentation but must also investigate the potential underlying cause of hyperglycemia. Both conditions most commonly include polyuria, polydipsia, and weight loss at initial onset 3-5. Rapid progression of symptoms is hallmark of DKA, with deterioration in less than 24hrs, while HHS has a more insidious onset of days to weeks 6. Other presenting symptoms with DKA include fatigue, dyspnea, nausea, vomiting, and/or abdominal pain 5-6. Neurologic symptoms such as lethargy, focal neurologic deficits, hemiparesis, seizures, and coma are more indicative of HHS 4, 6. Two key differences in point of care testing include blood glucose level and the presence of ketones. Blood glucose levels in DKA are moderately elevated >250mg/dl (typically ranging from 200-500), with ketones present in the urine. Blood glucose levels in HHS are more markedly elevated, >600mg/dl (frequently > 1,000 mg/dl) with minimal or no ketones present in the urine 6.
Physical exam findings in DKA may be minimal until the condition becomes more severe, at which point clinical features tend to overlap with HHS. Exam findings in both cases are consistent with dehydration (i.e. -poor skin turgor, dry mucous membranes, cool extremities) coupled with an associated deterioration in vital signs (i.e. hypotension and tachycardia) 4-6. Kusmal’s respirations and a fruity smell to the breath are generally associated with DKA given underlying changes include metabolic acidosis, though changes in mental status are generally more indicative of HHS 5. Identifying and treating the underlying cause of hyperglycemia is vital as this may range from a benign source that is easily corrected to potentially life-threatening pathology requiring emergent intervention. Common sources of hyperglycemia include new onset (or undiagnosed) diabetes, medication non-adherence, side effects of prescription drugs (e.g. corticosteroids, antipsychotics, diuretics, methadone, etc.), and the use of alcohol or drugs such as cocaine 4-6. Pathology that may create secondary hyperglycemia includes but is not limited to infection (e.g., pneumonia UTI, cellulitis, etc.), thyroid disease, venous thrombosis, myocardial infarction, cerebral vascular accident, and renal failure 4, 5.
Considerations for Emergency Management
With acute changes in blood glucose clinical findings the clinician’s ability to evaluate expediently will dictate required level of care. Chronic hyperglycemia warrants o
ngoing evaluation and management of blood glucose to ensure if complications arise patients know how and when to seek emergency care. Individuals who are asymptomatic at presentation and/or have an easily identified source of hyperglycemia may be a candidate for outpatient management. Clinical risk factors, such as age, frailty, medical comorbidities, and current medications may impact treatment decision making. In particular, advanced age increases risk for underlying major medical pathology and often complicates differential diagnosis. However, regardless of comorbidity emergent referral for ED evaluation is required with any changes in mental status, unstable vital signs, physical exam finding suggestive of dehydration, or elevated blood glucose coupled with ketones in the urine. If your evaluation includes DKA or HHS as part of a differential diagnosis referral to emergency medicine is warranted as both conditions will require inpatient management, ongoing insulin administration, intravenous fluid resuscitation, and addressing precipitating medical conditions is required regardless of the hyperglycemic complication.
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- Diabetes data and statistics. Centers for Disease Control and Prevention. https://www.cdc.gov/diabetes/data/index.html. Published June 15, 2021. Accessed February 6, 2022.
- Cost-effectiveness of diabetes interventions. Centers for Disease Control and Prevention. https://www.cdc.gov/chronicdisease/programs-impact/pop/diabetes.htm. Published May 17, 2021. Accessed February 6, 2022.
- Gosmanov AR, Gosmanova EO, Kitabchi AE. Hyperglycemic Crises: Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar State. [Updated 2021 May 9]. In: Feingold KR, Anawalt B, Boyce A, et al., editors. Endotext [Internet]. South Dartmouth (MA): MDText.com, Inc.; 2000. Available from: https://www.ncbi.nlm.nih.gov/books/NBK279052/
- Stoner GD. Hyperosmolar Hyperglycemic State. Am Fam Physician. 2017 Dec 1;96(11):729-736. PMID: 29431405.
- Westerberg DP. Diabetic ketoacidosis: evaluation and treatment. Am Fam Physician. 2013 Mar 1;87(5):337-46. PMID: 23547550.
- Hirsch, IB, Emmett, M. (2020). Diabetic ketoacidosis and hyperosmolar hyperglycemic state in adults: Clinical features, evaluation, and diagnosis. In: Nathan, DM, ed. UpToDate; 2020. Accessed February 6, 2022. https://www.uptodate.com/contents/diabetic-ketoacidosis-and-hyperosmolar-hyperglycemic-state-in-adults-clinical-features-evaluation-and-diagnosis?search=hhs&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H9