Diabetes Emergencies Nursing Guide 2026
⚕️ Medical Disclaimer: This content is for educational purposes only and is intended for licensed healthcare professionals. It does not constitute medical advice and should not replace clinical judgment, facility protocols, or physician orders. Always verify medications, doses, and procedures with your institution's guidelines.
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This article was created with AI assistance.
DKA vs. HHS comparison, insulin drip management, fluid resuscitation, potassium replacement rules, anion gap calculation, and hypoglycemia treatment for bedside nurses.
1. DKA vs. HHS Comparison
| Feature | DKA (Diabetic Ketoacidosis) | HHS (Hyperosmolar Hyperglycemic State) |
|---|
| Type of diabetes | Type 1 (primarily); also Type 2 | Type 2 (almost exclusively) |
| Onset | Rapid (hours to 24 hr) | Slow (days to weeks) |
| Blood glucose | >250 mg/dL (can be lower in euglycemic DKA) | >600 mg/dL (often 800–1200+) |
| pH | <7.30 (metabolic acidosis) | Normal or mildly low (>7.30) |
| Bicarbonate | <18 mEq/L (often <10) | >18 mEq/L (near normal) |
| Ketones | Present (serum + urine) | Absent or minimal (some insulin present) |
| Anion gap | Elevated (>12) | Normal or mildly elevated |
| Serum osmolality | Variable (may be <320) | >320 mOsm/kg (often >350) |
| Mental status | Alert to confused; rarely coma | Severe obtundation, coma (from hyperosmolality) |
| Fluid deficit | 3–6 liters | 8–12+ liters (profound dehydration) |
| Mortality | <5% in adults | 10–20% (older, sicker patients) |
2. DKA Pathophysiology
Insulin deficiency → cells cannot use glucose → starvation signal → counter-regulatory hormones (glucagon, cortisol, epinephrine) rise → lipolysis → fatty acid metabolism → KETONE BODIES (beta-hydroxybutyrate, acetoacetate, acetone)
Ketones are acids → high anion gap metabolic acidosis
Osmotic diuresis from hyperglycemia → polyuria, polydipsia, dehydration, electrolyte loss (K+, Na+, Cl-)
Classic presentation: Polyuria, polydipsia, polyphagia, nausea/vomiting, Kussmaul respirations (deep rapid breathing — body blowing off CO2 to compensate for acidosis), fruity/acetone breath, abdominal pain, dehydration
3. Anion Gap Calculation
Anion Gap = Na+ − (Cl- + HCO3-)
Normal: 8–12 mEq/L (some labs use 12–16 with albumin correction)
Elevated AG (>12) = MUDPILES: Methanol, Uremia, DKA, Propylene glycol, Isoniazid/Iron, Lactic acidosis, Ethylene glycol, Salicylates
Corrected AG for hypoalbuminemia: Add 2.5 mEq/L for every 1 g/dL albumin below 4.0 (low albumin falsely lowers AG)
4. DKA Treatment Protocol
Step 1 — Fluids FIRST
- NS 0.9% 1 liter bolus in first hour (IV fluids BEFORE insulin in most protocols)
- Then NS 250–500 mL/hr × next few hours, titrate to UO and clinical status
- When glucose reaches 200–250 mg/dL: switch to D5-0.45% NS or D5-NS (to prevent hypoglycemia while continuing insulin to clear ketones)
Step 2 — Potassium Replacement (CRITICAL)
Check potassium BEFORE starting insulin.
Insulin drives K+ into cells → can cause life-threatening hypokalemia if K+ is already low.
- K+ <3.3 mEq/L: HOLD insulin; replace potassium aggressively (20–40 mEq/hr IV) until K+ ≥3.5, THEN start insulin
- K+ 3.3–5.0: start insulin; add K+ to IV fluids (20–40 mEq per liter)
- K+ >5.0: start insulin; hold K+ replacement; check K+ q1–2h
Monitor K+ every 1–2 hours. Remember: patients are always total body K+ depleted even if serum K+ appears normal or high (acidosis shifts K+ out of cells).
Step 3 — Insulin
Standard DKA insulin protocol:
IV regular insulin infusion: start at 0.1 units/kg/hr (after K+ ≥3.3)
Some protocols: 0.1 units/kg IV bolus first, then 0.1 units/kg/hr
Goal glucose drop: 50–75 mg/dL per hour (not faster — cerebral edema risk, especially in children)
If glucose not dropping 50 mg/dL in first hour: double the insulin rate
When glucose reaches 200–250 mg/dL: reduce to 0.05 units/kg/hr; add dextrose to IV fluids; continue insulin until anion gap closed and bicarbonate >18
Do NOT stop insulin until: AG <12, pH >7.30, HCO3 >18, patient tolerating oral intake — then transition to subcutaneous insulin and overlap 2 hours before stopping drip
Step 4 — Bicarbonate?
Routine bicarbonate NOT recommended (even for severe acidosis) unless pH <6.9 — bicarbonate administration can worsen hypokalemia, cause paradoxical CNS acidosis, and may worsen cerebral edema. Fluids and insulin resolve the acidosis.
Step 5 — Phosphate
Replace if <1 mg/dL or symptomatic (respiratory muscle weakness); routine replacement not consistently shown to improve outcomes.
5. Cerebral Edema (DKA Complication)
Most dangerous complication, especially in pediatric DKA.
Risk factors: rapid correction of glucose/osmolality, too much fluid too fast, bicarbonate use, very young age
Signs: headache, change in mental status, vomiting, papilledema, bradycardia, hypertension (Cushing's triad) — may develop AFTER glucose is improving
Treatment: Mannitol 0.5–1 g/kg IV or 3% saline 5–10 mL/kg over 30 min; reduce IVF rate; call ICU
6. HHS Management
- Aggressive fluid replacement: 1 L NS in first hour, then NS or 0.45% NS at 250–500 mL/hr; total 8–12 L over 24–48 hours
- Insulin: lower doses than DKA (0.05 units/kg/hr); fluids alone often bring glucose down significantly first
- Glucose target: lower glucose slowly — aim for ~50 mg/dL/hr drop; target 250–300 mg/dL initially (not normal) until osmolality normalizes
- Treat precipitating cause: usually infection (pneumonia, UTI), MI, stroke
7. Hypoglycemia Management
| Scenario | Blood Glucose | Treatment |
|---|
| Mild (awake, able to swallow) | <70 mg/dL | 15-15 Rule: 15g fast-acting carbs (4 oz juice, 3–4 glucose tabs, 4 oz regular soda) → recheck in 15 minutes; repeat if still <70 |
| Moderate (confused but conscious) | <60 mg/dL | Oral glucose gel buccally OR if IV access: 25g D50W (1 amp = 50 mL of 50% dextrose) IV push |
| Severe (unconscious, no IV access) | <40 mg/dL | Glucagon 1 mg IM/SQ (glucagon kit); position lateral (vomiting risk after); establish IV access; then D50W when possible |
| ICU/continuous glucose monitoring | <70 mg/dL | D50W 1 amp IV; recheck q15 min; adjust insulin infusion; if on insulin drip — stop drip, treat, restart at lower rate |
ICU Glucose Target: 140–180 mg/dL (not tight control — NICE-SUGAR trial showed tighter control increased mortality). Avoid hypoglycemia (<70 mg/dL) at all costs.
NCLEX High-Yield: Diabetes Emergencies
- DKA: glucose >250 + ketones + pH <7.30 + anion gap >12
- HHS: glucose >600 + no significant ketones + osmolality >320 + altered mental status
- DKA treatment order: fluids first → check K+ → insulin (hold if K+ <3.3) → monitor
- K+ <3.3: HOLD insulin, replace K+ first
- Kussmaul respirations = deep rapid breathing; compensating for metabolic acidosis
- Fruity/acetone breath = ketones
- Anion gap = Na - (Cl + HCO3); normal 8–12
- Add dextrose to IV fluids when glucose hits 200–250 (don't stop insulin yet — still clearing ketones)
- Transition subQ insulin: overlap 2 hours before stopping insulin drip
- Cerebral edema: treat with mannitol or 3% NS; avoid in rapid correction
- Hypoglycemia: 15-15 rule if awake; D50W if IV access; glucagon IM if unconscious no IV
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