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Apr.20.2021

Hyperglycemia (Adult ED)

Clinical Description

  • Care of the Emergency Department patient seeking treatment for an elevated blood glucose level.

Key Information

  • It is essential to differentiate between DKA (diabetic ketoacidosis) and HHS (hyperosmolar hyperglycemic state) to successfully treat underlying cause. Both usually require fluid and insulin therapy; however, HHS may not require insulin therapy after fluid resuscitation. Precipitating factors must be identified and treated.
  • Underlying cause of DKA (diabetic ketoacidosis) or HHS (hyperosmolar hyperglycemic state) must be identified. Infection is a common precipitating factor.
  • Insulin therapy can cause an intracellular shift of potassium, further decreasing potassium levels resulting in cardiac dysrhythmia. Consider potassium replacement before insulin therapy, if potassium serum levels are low normal or low after fluid replacement.
  • Severe acute acidemia in DKA (diabetic ketoacidosis) may impact cardiac contractility and cause dysrhythmia.
  • For patients who typically maintain glycemic control with oral agents, insulin therapy may be required temporarily for treatment until ketonemia is resolved and hydration status has been stabilized.
  • Patients with HHS (hyperosmolar hyperglycemic state) have increased risk for thrombus formation.
  • Alternative causes for symptoms must be identified. For mental status changes and neurologic symptoms, other causes, such as stroke, must be considered.

Threats to Life, Limb or Function

  • acute neurologic injury
  • DKA (diabetic ketoacidosis)
  • dysrhythmia
  • hemodynamic instability
  • HHS (hyperosmolar hyperglycemic state)

Clinical Goals

By transition of care

A. The patient will achieve the following goals:
  • Goal: Acute Signs/Symptoms are Managed

  • Goal: Acceptable Pain Level Achieved

    Correlate Health Status

    • Correlate health status to:

      • history, comorbidity
      • age, developmental level
      • sex, gender identity
      • baseline assessment data
      • physiologic status
      • response to medication and interventions
      • psychosocial status, social determinants of health
      • barriers to accessing care and services
      • health literacy
      • cultural and spiritual preferences
      • safety risks
      • family interaction
      • plan for transition of care

    Hyperglycemia

    Associated Documentation

    • Hyperglycemia Management

    Presentation

    • abdominal pain
    • acetone breath
    • blurred vision
    • confusion
    • excessive thirst
    • frequent urination
    • Kussmaul respirations
    • nausea and vomiting
    • stupor
    • tachycardia
    • weakness

    Associated Signs/Symptoms

    • dehydration
    • unresponsive
    • weight loss

    Potential Causes

    • acute illness
    • alcohol-induced ketoacidosis
    • illicit drug use
    • infection
    • insulin deficiency
    • insulin pump interuption
    • medication noncompliance
    • medication-induced, such as glucocorticoid
    • new-onset diabetes
    • pregnancy

    Initial Assessment

    • fluid status
    • infection signs
    • mental status
    • neurologic status
    • respiratory rate, pattern, effort

    History

    • allergies
    • comorbidities
    • immunization status
    • last menstrual period (females of childbearing age)
    • medications
    • diabetes medication and equipment access
    • insulin administration (type, dose, delivery, schedule)
    • oral antihyperglycemic agent (type, dose, schedule)
    • recent illness
    • usual glycemic control
    • weight loss

    Laboratory Studies

    • anion gap
    • beta-hydroxybutyrate
    • blood glucose level
    • BUN (blood urea nitrogen)
    • CBC (complete blood count)
    • Hgb (hemoglobin) A1C
    • lactic acid
    • serum creatinine
    • serum electrolytes
    • serum ketones
    • serum osmolality
    • serum pH
    • VBG (venous blood gas)
    • urinalysis

    Diagnostics

    • ECG (electrocardiogram)

    Potential Additional Testing

    • ABG (arterial blood gas)
    • cardiac biomarkers
    • coagulation studies
    • chest x-ray
    • cultures (blood or urine)
    • pregnancy test (females of childbearing age)
    • radiology studies (to identify infection source)
    • serum amylase
    • urinalysis
    • urine drug screen
    • urine ketones

    Problem Intervention

    Minimize and Manage Fluid and Electrolyte Deficit

    • Assess fluid status and ability to take oral fluids; if unable to provide or achieve oral intake, provide intravenous fluid therapy for fluid and electrolyte replacement.
    • Monitor intake, output and laboratory value trends; advocate for adjustment in treatment with imbalance.
    • Observe respiratory effort and breath sounds.
    • Monitor ECG (electrocardiographic monitoring), oxygen saturation, cardiovascular, neurologic (including mental status) and hemodynamic status; watch for ECG changes that may indicate fluctuation in serum electrolyte levels, such as potassium.
    • Provide treatment for nausea, vomiting and pain to decrease worsening dehydration and promote patient comfort.

    Problem Intervention

    Monitor and Manage Blood Glucose Level

    • Prepare for medication administration, which may include intravenous fluids, potassium supplement or intravenous or subcutaneous insulin therapy. Begin rehydration before insulin therapy.
    • Evaluate function of patient's own insulin pump, if present. Assess for malfunction, tubing kinks, leakage or dislodgement from site. Turn off patient's insulin pump if being treated with other insulin method.
    • Perform frequent glucose checks; monitor trends and assess for hypoglycemia risk.
    • Monitor physiologic response.

    Problem Intervention

    Initiate Consult or Referral

    • Coordinate care transition, such as hospital admission or discharge.
    • Facilitate contact which may include endocrinologist, primary care provider and diabetes education resource.

    Education

    General Emergency Education

    Teaching Focus

    • symptom/problem overview

    • risk factors/triggers

    • self-management

    • assistive device

    • diagnostic test

    • diet modification

    • medical device/equipment use

    • medication administration

    • opioid medication management

    • orthopaedic device

    • safe medication disposal

    • smoking cessation

    • wound care

    Population-Specific Considerations

    Forensics and Legal

    • Utilize local, state/province, federal requirements and hospital policy and protocols to manage patient care involving forensics, protective services, workman’s compensation and mandatory reportable events and illness.

    Human Trafficking

    • Human trafficking victims most frequently seek healthcare services from Emergency Departments. Healthcare professionals, alert to signs of trafficking, can guide supportive care for victims.
    • Trafficked individuals may be male or female and engaged in sex work or other forced labor. High-risk signs requiring more direct questioning about exploitation include, among others, current employment in a high-risk industry, prior sexually transmitted infections, recent immigration, undocumented immigrant status and other vulnerable and minority populations.

    Geriatric

    • Older adults are at risk for HHS (hyperosmolar hyperglycemic state) and may present with profound dehydration with very high blood glucose, not accompanied by ketoacidosis. Look for, and treat, underlying cause. It is often precipitated by an acute illness, such as pneumonia, urinary tract infection, severe diarrhea or other stresses that result in fluid deficit.

    Pregnancy

    • Beyond 20 weeks gestation, supine position should be avoided. Maternal position should be lateral or lateral tilt to prevent compression of the inferior vena cava and aorta by the pregnant uterus.
    • Pregnant women with diabetes can develop DKA (diabetic ketoacidosis) at lower blood glucose levels than nonpregnant diabetic patients. Left untreated it can have severe effects on the fetus and the mother.

    Quality Measures

    • NQF 0496. Median Time from ED arrival to ED Departure for Discharged ED Patients
      Median time from emergency department arrival to time of departure from the emergency room for patients discharged from the emergency department.
      Steward: Centers for Medicare and Medicaid Services
      Care Setting: ED, Hospital
      National Quality Forum-endorsed measure
      Last Edited: 10/11/2017
    • NQF 0495. Median Time from ED arrival to ED Departure for Admitted ED Patients
      Median time from emergency department arrival to time of departure from the emergency room for patients admitted to the facility from the emergency department.
      Steward: Centers for Medicare and Medicaid Services
      Care Setting: ED, Hospital
      National Quality Forum-endorsed measure
      Last Edited: 10/11/2017

    References

    • American Diabetes Association. American Diabetes Association Standards of Medical Care in Diabetes--2021. Diabetes Care. 2021, January;44(1), S1-S232. Source[Clinical Practice Guidelines]
    • American Diabetes Association. American Diabetes Association Standards of Medical Care in Diabetes--2021. Diabetes Care. 2021, January;44(1), S1-S232. Source[Clinical Practice Guidelines]
    • American Diabetes Association. American Diabetes Association Standards of Medical Care in Diabetes--2021. Diabetes Care. 2021, January;44(1), S1-S232. Source[Clinical Practice Guidelines]
    • American Diabetes Association. Standards of medical care in diabetes. Diabetes Care. 2020;43(Supplement 1), S1-S211. doi:10.2337/dc20-SPPC Source[Quality Measures,Clinical Practice Guidelines]
    • American Heart Association. (2016). Advanced cardiovascular life support provider manual. USA: American Heart Association. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Andrade-Castellanos, C. A.; Colunga-Lozano, L. E.; Delgado-Figueroa, N.; Gonzalez-Padilla, D. A. Subcutaneous rapid-acting insulin analogues for diabetic ketoacidosis. Cochrane Database of Systematic Reviews. 2016;(1) doi:10.1002/14651858.CD011281.pub2 [Metasynthesis,Meta-analysis,Systematic Review]
    • Beltran, G.. Diabetic emergencies: New strategies for an old disease. Emergency Medicine Practice. 2014;16(6), 1-19. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Cardoso, L.; Vicente, N.; Rodrigues, D.; Gomes, L.; Carrilho, F. Controversies in the management of hyperglycaemic emergencies in adults with diabetes. Metabolism. 2017;68, 43-54. doi:http://dx.doi.org/10.1016/j.metabol.2016.11.010 [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Centers for Medicare & Medicaid Services (CMS). (2017). NQF 0495. Median Time from ED Arrival to ED Departure for Admitted ED Patients. Source[Quality Measures,Clinical Practice Guidelines]
    • Centers for Medicare & Medicaid Services (CMS). (2017). NQF 0496. Median time from ED arrival to ED departure for discharged ED patients. Source[Quality Measures,Clinical Practice Guidelines]
    • Chua, H. R.; Schneider, A.; Bellomo, R. Bicarbonate in diabetic ketoacidosis-a systematic review. Annals of Intensive Care. 2011;1(1), 43123. [Metasynthesis,Meta-analysis,Systematic Review]
    • Dingle, H.E.; Slovis, C.. Diabetic hyperglycemic emergencies: a systematic approach. Emergency medicine practice. 2020;22(2), 1 - 20. [Review Articles]
    • Dingle, H.E.; Slovis, C.. Diabetic hyperglycemic emergencies: a systematic approach. Emergency medicine practice. 2020;22(2), 1 - 20. [Review Articles]
    • Dingle, H.E.; Slovis, C.. Diabetic hyperglycemic emergencies: a systematic approach. Emergency medicine practice. 2020;22(2), 1 - 20. [Review Articles]
    • Emergency Nurses Association. (2018). Emergency nursing core curriculum. St. Louis: Elsevier. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Emergency Nurses Association. (2020). Sweet, V.; Foley, A (Eds.), Sheehy's Emergency Nursing Principles and Practice. St. Louis: Mosby, Elsevier. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Epstein, E.; McDougall, M.; Thomas, P.. Intravenous fluids in hospital: Practical approaches. British Journal of Hospital Medicine. 2017;78(4), C50-C54. doi:10.12968/hmed.2017.78.4.C50 [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Fayfman, M.; Pasquel, F. J.; Umpierrez, G. E.. Management of hyperglycemic crises: Diabetic ketoacidosis and hyperglycemic hyperosmolar state. Medical Clinics of North America. 2017;101(3), 587-606. doi:10.1016/j.mcna.2016.12.011 Source[Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Goguen, J.; Gilbert, J. Hyperglycemic emergencies in adults. Canadian Journal of Diabetes. 2018;42, S109-S114. doi:10.1016/j.jcjd.2017.10.013 Source[Quality Measures,Clinical Practice Guidelines]
    • Greenbaum, J.. Identifying victims of human trafficking in the emergency department. Clinical Pediatric Emergency Medicine. 2016;17(4), 241-248. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Hammond, B. B.; Zimmermann, P. G. (2013). Sheehy's manual of emergency care. St. Louis: Mosby, Elsevier. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Long, B.; Willis, G. C.; Lentz, S.; Koyfman, A.; Gottlieb, M.. Evaluation and Management of the Critically Ill Adult With Diabetic Ketoacidosis. Journal of Emergency Medicine. 2020;59(3), 371-383. doi:10.1016/j.jemermed.2020.06.059 [Review Articles]
    • Long, B.; Willis, G. C.; Lentz, S.; Koyfman, A.; Gottlieb, M.. Evaluation and Management of the Critically Ill Adult With Diabetic Ketoacidosis. Journal of Emergency Medicine. 2020;59(3), 371-383. doi:10.1016/j.jemermed.2020.06.059 [Review Articles]
    • Long, B.; Willis, G. C.; Lentz, S.; Koyfman, A.; Gottlieb, M.. Evaluation and Management of the Critically Ill Adult With Diabetic Ketoacidosis. Journal of Emergency Medicine. 2020;59(3), 371-383. doi:10.1016/j.jemermed.2020.06.059 [Review Articles]
    • National Institute for Health and Care Excellence. (2013 [Updated 2017]). Intravenous fluid therapy in adults in hospital . Source[Quality Measures,Clinical Practice Guidelines]
    • Siddiqi, L.; VanAarsen, K.; Iansavichene, A.; Yan, J. Risk factors for adverse outcomes in adult and pediatric patients with hyperglycemia presenting to the emergency department: A systematic review. Canadian Journal of Diabetes. 2019;43(5), 361-369. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • Troiano, N. H.; Witcher, P. M.; McMurtry Baird, S.. (2019). AWHONN: High-risk & critical care obstetrics. Philadelphia: Wolters Kluwer. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
    • U. S. Department of Health and Human Services. (2017). Human trafficking webinar for health care providers: SOAR to health and wellness. Source[Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]

    Disclaimer

    Clinical Practice Guidelines represent a consistent/standardized approach to the care of patients with specific diagnoses. Care should always be individualized by adding patient specific information to the Plan of Care.

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