Hyperglycemia

Table of Contents

Aliases

Diabetic ketoacidosis (DKA), hyperosmolar hyperglycemic state, hyperosmolar non-ketotic coma, diabetes

Patient Care Goals

  1. Limit morbidity from hyperglycemia by:
  2. Appropriate use of glucose monitoring
  3. Appropriate hydration for hyperglycemia

Patient Presentation

Inclusion Criteria

  1. Adult or pediatric patient with altered level of consciousness [see Altered Mental Status guideline]
  2. Adult or pediatric patient with stroke symptoms (e.g. hemiparesis, dysarthria) [see Suspected Stroke/Transient Ischemic Attack guideline]
  3. Adult or pediatric patient with seizure [see Seizures guideline]
  4. Adult or pediatric patient with symptoms of hyperglycemia (e.g. polyuria, polydipsia, weakness, dizziness, abdominal pain, tachypnea)
  5. Adult or pediatric patient with history of diabetes and other medical symptoms

Exclusion Criteria

Patient in cardiac arrest.

Patient Management

Assessment

  1. Monitoring:
    1. Check blood glucose level
  2. Secondary survey pertinent to altered blood glucose level:
    1. Constitutional: assess for tachycardia, hypotension, and tachypnea
    2. Eyes: assess for sunken eyes from dehydration
    3. Nose /mouth/ears: assess for dry mucus membranes or tongue bite from seizure
    4. Neurologic:
      1. Assess GCS and mental status
      2. Assess for focal neurologic deficit: motor and sensory
    5. Evaluate for possible concomitant sepsis and septic shock [see Shock guideline]
    6. Obtain 12-lead EKG to assess for findings consistent with hyperkalemia: Slow rate, or wide complex, or peaked T waves, etc.
    7. If blood glucose > 550 mg/dL, monitor continuous waveform capnography.
      1. When EtCO2 < 21 mmHg, alert hospital that the patient has Diabetic Ketoacidosis (DKA)

Treatment and Interventions

  1. If altered level of consciousness, stroke, or sepsis/septic shock, treat per Altered Mental Status, Suspected Stroke/Transient Ischemic Attack, or Shock guidelines accordingly
  2. If glucose greater than 250 mg/dL with symptoms of dehydration, vomiting, abdominal pain, or altered level of consciousness:
    1. Provide volume expansion with normal saline bolus
      1. Adult: Normal saline 1 L bolus IV; reassess and rebolus 1L if indicated
      2. Pediatric: Normal saline 10 mL/kg, max of 1 L bolus IV, reassess, and repeat up to 30 mL/kg or 2 L total
  3. If findings of hyperkalemia (Wide Complex QRS) are present, administer IV fluids and consider administration of:
    1. Calcium chloride 20 mg/kg (0.2 mL/kg) up to 1 gm (10 mL) IV/IO over 5 minutes, ensure IV patency and do not exceed 1 mL per minute
    2. Albuterol 10 mg via small volume nebulizer
    3. Sodium bicarbonate 1 mEq /kg (max dose of 50 mEq) IV bolus over 5 minutes
  4. Reassess patient
    1. Reassess vital signs, mental status, and signs of dehydration
    2. If mental status changes, reassess blood glucose level and provide appropriate treatment if hypoglycemia has developed
  5. Disposition
    1. Transport to closest appropriate receiving facility

Notes – Hyperglycemia