Category: Home

Hyperglycemia and emergency room visits

Hyperglycemia and emergency room visits

Diabetes Hyperglycemia and emergency room visits. Eemrgency our knowledge, this is the first comprehensive report to assess both Essential vitamins for athletes and HHS trends viists both ED and inpatient settings. Health care utilization visit burden of diabetic ketoacidosis in the U. Hypeerglycemia, Blood sugar regulation University School of Cisits Last Updated: November, Case Study A year-male with unknown Digestive health and food intolerances Diabetic nephropathy holistic approaches is found down anf subway platform and is visifs to the hospital by EMS. Charles RA, Bee YM, Eng PH, et al. There have been no randomized trials that have studied strategies for potassium replacement. In patients suspected of having DKA or HHS, additional tests should be obtained: Basic metabolic profile Complete blood count often obtained when suspicious for an infectious etiology, sensitive, not specific Blood gas determination venous blood gas sample provides accurate information regarding blood pH and closely approximates that of arterial pH Additional electrolytes phosphorus, magnesium may be important in patients profoundly dehydrated Electrocardiogram ECG In patients with marked acidemia or severe hyperglycemia, extracellular potassium shifts may result in ECG manifestations of hyperkalemia despite total body losses Additional testing based on patient presentation lipase, hepatic functions, chest radiograph, blood cultures, etc.

Stephen R. Benoit emefgency, Israel HoraFrancisco J. Pasquel Hyperglycemis, Edward W. Gregg Lowering blood sugar, Ann L.

Albright emerfency, Giuseppina Imperatore; Trends visuts Emergency Hyperglhcemia Visits and Inpatient Vjsits for Hyperglycemic Crises emerency Adults Ans Diabetes in Hyperglycemia and emergency room visits U.

Diabetes Care 1 Visis ; vixits 5 : Hypetglycemia To report U. national rook rates and trends in diabetic ketoacidosis DKA and hyperglycemic snd state HHS among adults, in both rooom emergency department ED and inpatient settings.

We analyzed data Finding joy in movement 1 January through Blood sugar regulation September from the Nationwide Emergency Department Sample and National Inpatient Sample to characterize ED Hypergltcemia and inpatient admissions abd DKA and HHS.

Linear trends from to were Potassium and breastfeeding using Joinpoint software. Inthere were a total ofand dmergency, events for DKA Hyperglycemka HHS, respectively.

The majority of Hylerglycemia events bisits in young adults aged 18—44 years Overall, event rates for DKA significantly increased from to emergencj both ED annual percentage change [APC] A similar trend was Diabetic nephropathy holistic approaches for Roo, APC The increase was in all age-groups and in both men and women.

Causes emeregncy increased rates of hyperglycemic events are unknown. More detailed data are rooom to investigate the etiology and determine prevention strategies. Uncontrolled Hyperglycemua leading to diabetic ketoacidosis Orom and hyperglycemic hyperosmolar rooj HHS Hy;erglycemia life-threatening, Hylerglycemia metabolic complications of diabetes, znd disease affecting more than 30 million people Hyperglycemja the U.

Visitts causes of DKA include newly presenting disease, infections, and inadequate treatment 2. HHS is less foom Blood sugar regulation be visist at diabetes diagnosis, and common precipitating conditions include urinary tract infections, pneumonia, and acute cardiovascular events 2.

national data exist for HHS incidence. However, questions remain about trends in HHS as well as Vsits and Hypetglycemia trends in emergency department Hyperglycemia and emergency room visits settings. By evaluating ED and inpatient data simultaneously, we address the potential ascertainment bias associated vixits changes in hospital roon thresholds.

We also present the numerator data by aand type, which have been lacking Hypdrglycemia the past. To our knowledge, this is the first comprehensive report to assess both DKA adn HHS trends in both Diabetic coma recovery and inpatient settings.

NEDS and NIS, the Hyperglyvemia all-payer Hypergylcemia and inpatient databases in the U. Rehabilitation and Diabetic nephropathy holistic approaches acute care hospitals are excluded Hypergglycemia NIS.

Both NEDS and NIS include International Hypdrglycemia of DiseasesRelaxation techniques for pain relief revision, Clinical Modification Emeregncy codes as well as patient demographics, hospital characteristics, payment Hydration plan for preventing heat exhaustion, patient disposition, and total charges.

NEDS and NIS are event-based anv, so Hyperrglycemia were not able to account for multiple admissions for an individual person within a single year. Forwe Strengthen attention focus data through 30 Visuts because starting on 1 October, coding shifted from ICDCM to ICDCM.

These estimates are vsits in Hypsrglycemia denominator for rate visjts, both emergejcy and Diabetic nephropathy holistic approaches specific vissits. NHIS is Grape Wine Regions Guide nationally representative, in-person household survey that relies on self-reported behaviors Hypergltcemia medical conditions Hyperg,ycemia.

Respondents are asked, other than during pregnancy, whether a visitd care professional had Hypreglycemia them that they emergecy diabetes. Orom does not distinguish between diabetes type. DKA and HHS ED visits and inpatient admissions were defined by a first-listed ICDCM diagnosis code of Diabetes type was based on the ICDCM fifth digit subclassification: a 1 or 3 was considered type 1 diabetes, and 0 and 2 were considered type 2 diabetes.

If there was a discrepancy in diabetes type among multiple codes for the same patient, the type was considered unknown. ICDCM coding in NEDS and NIS has not been validated against medical records for DKA, HHS, or type 1 or type 2 diabetes.

Payers in NEDS and NIS are the expected primary payer, including Medicare, Medicaid, private insurance, and uninsured 4. In NHIS, if a participant had more than one kind of health insurance that included Medicare Part A coverage e.

In general, if the survey participant was retired, we assumed Medicare paid first. Otherwise, we assumed private insurance was the primary payer. We assumed the survey participant was working for a large employer when employer size was a factor in determining the primary payer.

The lowest quartile was considered the poorest population. region for both the ED and inpatient settings. To avoid double counting, we excluded ED visits where the disposition was admission to the hospital because these hyperglycemic episodes were accounted for in the inpatient data. The weighted results estimate the number of ED visits and hospital admissions in the U.

due to these conditions. Event rates from to were calculated for each of the conditions in both ED and inpatient settings by using the number of adults with the specified condition from NEDS and NIS in the numerator divided by the adult population with diagnosed diabetes from NHIS.

Inthe denominator from NHIS was adjusted to account for the partial year used in the numerator by multiplying by 0. We used the U. We used SAS-callable SUDAAN RTI International to account for the complex sampling design in NEDS, NIS, and NHIS, and the Taylor series linearization was used to estimate the variance of the ratio of the numerator and denominator.

Because previous studies have already identified an increase in DKA rates starting inwe used Joinpoint Trend Analysis Software version 4.

With the exception of age-group, all rates were age-adjusted. We were not able to calculate rates by diabetes type because this question was not asked in NHIS during the study period. Joinpoint Trend Analysis can identify statistically significant changes in linear trends direction or magnitude and calculates the annual percentage change APC for each identified time segment 7.

To assess for a linear trend over the 7-year period from towe selected a maximum of zero joinpoints. Inthere were an estimated 16, U.

adult ED visits for DKA where the patient was not admitted to an inpatient unit Table 1. In that same year, there wereadult admissions to inpatient settings in U. hospitals for DKA. Of all adults with DKA, in From tothere was an increase in the proportion of adults with DKA having public health insurance i.

In both years, the Northeast region had the lowest number of DKA episodes, while the South had the highest Table 1. AMA, left against medical advice; NA, not available; SNF, skilled nursing facility. Overall, U. adult nonadmitted ED visit rates for DKA doubled from to from 1. In the inpatient setting, DKA rates increased In the inpatient setting, all age-groups experienced a significant increase in DKA rates from to However, the 18—year-old age-group had the highest rates Patients with Medicare or Medicaid as the primary payer had the highest DKA event rates in both the ED and inpatient settings.

An increasing trend in DKA rates in the ED setting was seen for all but the uninsured. In the inpatient setting, Medicaid and private insurance had increasing DKA trends.

DKA rates increased in the ED setting in the Midwest and West, and in the inpatient setting, rates increased in the Midwest, South, and West. InDKA rates were highest in the South Age-adjusted DKA ED and hospitalization rates per 1, adults with diagnosed diabetes, — Numerator data are from the NEDS and NIS.

Dots are observed annual values. The lines are modeled using Joinpoint Trend Analysis Software. The U. Inthere were an estimated 2, U. adult ED visits for HHS where the patient was not admitted to an inpatient unit Table 2. In that same year, there were 24, adult admissions to inpatient settings in U.

hospitals for HHS. Overall, in Similar to DKA, from tothere was an increase in the proportion of adults with HHS having public health insurance i. In Approximately a quarter were discharged to skilled nursing facilities, other short-term hospitals, or with home care.

From tothe proportion dying in the hospital setting declined from 1. The West region had the lowest number of HHS episodes, while the South had the highest Table 2. adult nonadmitted ED visit rates for HHS more than doubled from to from 1.

In the inpatient setting, HHS rates increased The significantly increasing trend was seen in both ED and inpatient settings for both men and women and for all age-groups Supplementary Tables 3 and 4.

Patients with Medicare or Medicaid as the primary payer had the highest HHS event rates in the inpatient setting but varied in the ED setting. The privately insured had consistently lower HHS rates in both settings. An increasing trend in HHS rates in the ED setting was seen for patients with public sponsored programs but not for privately insured or uninsured patients.

Only the population with private insurance as the primary payer had a significant increase in HHS events in the inpatient setting. HHS rates increased in the ED setting in all regions of the country, and in the inpatient setting, rates increased in all but the Northeast region.

Ininpatient HHS rates were highest in the South

: Hyperglycemia and emergency room visits

Managing Hyperglycemia in Emergency Department Patients

However, hyperkalemia on laboratory studies is not uncommon. To prevent hypokalemia, potassium replacement should be initiated after serum levels fall below the upper level of normal. Rarely, DKA patients may present with hypokalemia. How much insulin is to be given and by which route has been the subject of much debate.

Goyal et al prospectively compared the utility of the initial insulin bolus in patients. In this study, both groups were similar at baseline and received the same amount of IV fluids, as well as insulin infusions.

There was no significant difference in the incidence of hypoglycemia, rate of serum glucose change, anion gap change, or length of ED or hospital stay. Most of the current studies have focused specifically on bolus vs. no bolus in the DKA patient population.

How does this translate to the treatment of HHS? However, understanding the pathophysiology underlying both DKA and HHS leads to plausible conclusions. Unlike DKA, in HHS there is only a relative deficiency of insulin and no ketone production.

Endogenous insulin production is adequate to prevent a total catabolic state, however, there is insufficient insulin to permit tissue utilization of glucose and thus hyperglycemia occurs. The foundation of the treatment of HHS centers more around the replacement of fluids given the patients often large fluid deficit L.

In HHS, insulin is administered after initiation of fluid replacement with the goal to slowly lower glucose, not clear ketones. Given this major difference between the two etiologies, and the fact that insulin bolus in DKA has been shown to have no clear benefit, the omittance of the insulin bolus in HHS seems reasonable.

He reports increased thirst and urinary frequency over the last several weeks, but otherwise feels well. Vitals are within normal limits.

Exam shows a well-appearing, overweight female with dry mucous membranes. Laboratory studies reveal no ketones, no anion gap, and no acidosis.

According to ADA guidelines 8 , a diagnosis of diabetes can be made from the ED using the following criteria:. Driver et al. performed a single center, retrospective cohort chart review to determine if there was an association between discharge glucose and 7-day adverse outcomes.

Adverse outcomes was defined as:. Therefore, attaining a specific glucose goal before discharge in patients with hyperglycemia may be less important than originally thought.

Management should focus on improving long-term glucose management and arranging good follow up. National Diabetes Statistics Report Estimates of diabetes and its burden in the United States.

Published online Oliver WD, Willis GC, Hines MC, Hayes BD. Comparison of Plasma-Lyte A and Sodium Chloride 0. Hosp Pharm. doi: Epub Feb PMID: ; PMCID: PMC Goyal, N. Utility of initial bolus insulin in the treatment of diabetic ketoacidosis. The Journal of emergency medicine , 38 4 , — Clinical presentation, diagnosis, and initial evaluation of diabetes mellitus in adults — UpToDate.

Accessed October 30th, Butler AE, Misselbrook D. Distinguishing between type 1 and type 2 diabetes. Ginde AA, Delaney KE, Pallin DJ, Camargo CA. Multicenter Survey of Emergency Physician Management and Referral for Hyperglycemia. J Emerg Med. Charfen MA, Ipp E, Kaji AH, Saleh T, Qazi MF, Lewis RJ.

Detection of Undiagnosed Diabetes and Prediabetic States in High-risk Emergency Department Patients. Acad Emerg Med. American Diabetes Association. Classification and Diagnosis of Diabetes: Standards of Medical Care in Diabetes— Driver BE, Olives TD, Bischof JE, Salmen MR, Miner JR.

Discharge Glucose Is Not Associated With Short-Term Adverse Outcomes in Emergency Department Patients With Moderate to Severe Hyperglycemia. Ann Emerg Med. Written by Jazmyn Shaw, MD PGY-1 University of Cincinnati Department of Emergency Medicine.

Peer Review, Editing, and Posting - Jeffery Hill, MD MEd, Associate Professor, University of Cincinnati Dept of Emergency Medicine. Training in, and managing, the SRU is one of the crown jewels of our residency.

It is where the sickest of the sick patients are found in our ED. It is a crucible, a test of knowledge and strength, and a true manifestation of the tripartite mission of our department: Leadership, Excellence, and Opportunity.

EMS Equipment Medications Procedures Quick Reference Air Care Secure. It may be beneficial to give the patient their first dose of long-acting insulin while still in the ED Consider the timing of administration of the long-acting insulin you give, as changing the timing of the dose will require careful attention.

The patient should also be discharged with a glucometer and other materials for glucose monitoring, with the plan to check their blood sugar at least twice per day The patient should be educated on the signs and symptoms of hypoglycemia and understand how to self-rescue should hypoglycemia occur Case 1 : The patient is discharged home with primary care follow-up for further testing, as he is asymptomatic and does not meet ADA criteria for diagnosis of diabetes.

Case 2 : The patient meets criteria for diagnosis of diabetes. Your email address will not be published. Save my name, email, and website in this browser for the next time I comment. Notify me of follow-up comments by email. Notify me of new posts by email.

We are actively recruiting both new topics and authors. This project is rolling and you can submit an idea or write-up at any time!

Contact us at editors emdocs. Wheezing and Stridor. Popular Recent Comments FROM THE ARCHIVES emDOCs Podcast — Episode The Metric That Really Matters ABG Versus VBG in the Emergency Department ECG Pointers: Recurrent and Refractory Torsades de Pointes emDOCs Podcast — Episode GLP-1 Agonist Complications Policy Playbook: Labor Actions and Unionization in Healthcare EMDOCS IN YOUR MAILBOX Enter your email address to receive notifications of new posts by email.

emDocs is licensed under a Creative Commons Attribution 4. Powered by Gomalthemes. Toggle navigation.

Menu All Content. Previous Post. Next Post. Management and Disposition of Adults with New-Onset Hyperglycemia without Hyperglycemic Emergency. Jul 5th, Xavier Schwartz categories: practice updates. Introduction Emergency physicians are well versed in the management of acute diabetic emergencies such as hypoglycemia, diabetic ketoacidosis DKA , and hyperglycemic hyperosmolar state HHS.

Does this hyperglycemic patient have a new diagnosis of diabetes? History Commonly, hyperglycemic patients present with polyuria, polydipsia, weight loss, and vision changes Hyperglycemic patients require three separate assessments: Evaluation for hyperglycemic emergencies diabetic ketoacidosis and hyperglycemic hyperosmolar state Evaluation of the etiology for the hyperglycemia such as infection, ischemia stroke, pulmonary embolism, acute coronary syndrome , medications steroids , malignancy, and pregnancy.

Evaluation for type 1 versus type 2 diabetes. Key elements of the history include duration of symptoms and personal or family history of diabetes or autoimmune disorders. A recent history of marked weight loss and other severe symptoms in a short period of time should raise suspicion for type 1 diabetes Physical Exam General Appearance: normal or thin body habitus should heighten suspicion for type 1 8.

Cardiovascular and mucous membranes: hyperglycemia related dehydration can result in dry mucous membranes and tachycardia. Respiratory: tachypnea suggestive of DKA and signs of pulmonary infection Neurologic: altered mentation suggestive of HHS , and decreased sensation in the distal extremities indicating neuropathy secondary to chronic hyperglycemia Skin: acanthosis nigricans, signs of infection, wounds on the feet, and decreased skin turgor Laboratory Evaluation Most patients with type 2 diabetes present without symptoms, and their hyperglycemia will be an incidental finding Symptomatic hyperglycemic patients may require an evaluation for electrolyte derangements, DKA, and hyperosmolarity with: Point of care glucose Basic metabolic panel Complete blood count Urinalysis Urine pregnancy test for women of childbearing age Venous blood gas Serum osmolality Beta-hydroxybutyrate A new diagnosis of diabetes can be made in the ED using the ADA criteria.

Disposition Generally, the following categories can help determine disposition of the stable diabetic patient. Initiation of outpatient long-acting insulin therapy from the ED has several requirements to be successful: Hospital nursing, emergency department administration, endocrine, PCP support Availability of targeted patient education for safe administration of insulin and glucose monitoring Availability of materials to provide the patient on discharge glucometer and test strips Communication and coordination of care with outpatient providers If the above requirements are met, consider starting long-acting insulin such as glargine 10 units daily or glargine 0.

Take-Home Points Type 1 autoimmune diabetes can present in adults. Consider type 1 diabetes in adult patients with hyperglycemia and severe weight loss, polyuria, or polydipsia.

This mandates an ED endocrinology consult or hospital admission. Disposition of these patients will vary by practice environment. Consider initiation of long-acting glargine at 0.

Case Conclusions Case 1 : The patient is discharged home with primary care follow-up for further testing, as he is asymptomatic and does not meet ADA criteria for diagnosis of diabetes.

Limited communication and management of emergency department hyperglycemia in hospitalized patients. J Hosp Med. Treatment of inpatient hyperglycemia beginning in the emergency department: A randomized trial using insulins aspart and detemir compared with usual care.

Impact of a Subcutaneous Insulin Protocol in the Emergency Department: Rush Emergency Department Hyperglycemia Intervention REDHI. J Emerg Med. Are lower fasting plasma glucose levels at diagnosis of type 2 diabetes associated with improved outcomes?

Prospective Diabetes Study Diabetes Care. Estimates of diabetes and its burden in the United States. Published online Ford W, Self WH, Slovis C, McNaughton CD. Diabetes in the Emergency Department and Hospital: Acute Care of Diabetes Patients. Curr Emerg Hosp Med Rep. Estimated Risk for Undiagnosed Diabetes in the Emergency Department: A Multicenter Survey.

Acad Emerg Med. x American Diabetes Association. Classification and Diagnosis of Diabetes: Standards of Medical Care in Diabetes— National Hospital Ambulatory Medical Care Survey: Emergency Department Summary Tables.

Clinical presentation, diagnosis, and initial evaluation of diabetes mellitus in adults — UpToDate. Accessed January 25, Accessed February 27, Accessed February 24, Frequency and phenotype of type 1 diabetes in the first six decades of life: a cross-sectional, genetically stratified survival analysis from UK Biobank.

Lancet Diabetes Endocrinol. Pharmacologic Approaches to Glycemic Treatment. Distinguishing between type 1 and type 2 diabetes. m Barker JM. Clinical review: Type 1 diabetes-associated autoimmunity: natural history, genetic associations, and screening.

J Clin Endocrinol Metab. Differentiation of Diabetes by Pathophysiology, Natural History, and Prognosis. Family history and prevalence of diabetes in the U. population: the 6-year results from the National Health and Nutrition Examination Survey Characteristics of newly diagnosed adults with type 1 diabetes in the UK and evolution of glycaemic control, body mass index and Charlson comorbidity index over the first 5 years after diagnosis.

Prim Care Diabetes. Can clinical features be used to differentiate type 1 from type 2 diabetes? A systematic review of the literature. BMJ Open. Synergy to reduce emergency department visits for uncontrolled hyperglycemia.

Diabetes Educ. Discharge Glucose Is Not Associated With Short-Term Adverse Outcomes in Emergency Department Patients With Moderate to Severe Hyperglycemia. Ann Emerg Med. Multicenter Survey of Emergency Physician Management and Referral for Hyperglycemia. The Synergy To Enable Glycemic Control Following Emergency Department Discharge Program For Adults With Type 2 Diabetes: STEP-Diabetes.

Endocr Pract Off J Am Coll Endocrinol Am Assoc Clin Endocrinol. OR Charfen MA, Ipp E, Kaji AH, Saleh T, Qazi MF, Lewis RJ. Detection of Undiagnosed Diabetes and Prediabetic States in High-risk Emergency Department Patients. x Bowen ME, Xuan L, Lingvay I, Halm EA. Random Blood Glucose: A Robust Risk Factor For Type 2 Diabetes.

FROM THE ARCHIVES

Otherwise, we assumed private insurance was the primary payer. We assumed the survey participant was working for a large employer when employer size was a factor in determining the primary payer. The lowest quartile was considered the poorest population. region for both the ED and inpatient settings.

To avoid double counting, we excluded ED visits where the disposition was admission to the hospital because these hyperglycemic episodes were accounted for in the inpatient data. The weighted results estimate the number of ED visits and hospital admissions in the U.

due to these conditions. Event rates from to were calculated for each of the conditions in both ED and inpatient settings by using the number of adults with the specified condition from NEDS and NIS in the numerator divided by the adult population with diagnosed diabetes from NHIS.

In , the denominator from NHIS was adjusted to account for the partial year used in the numerator by multiplying by 0. We used the U. We used SAS-callable SUDAAN RTI International to account for the complex sampling design in NEDS, NIS, and NHIS, and the Taylor series linearization was used to estimate the variance of the ratio of the numerator and denominator.

Because previous studies have already identified an increase in DKA rates starting in , we used Joinpoint Trend Analysis Software version 4.

With the exception of age-group, all rates were age-adjusted. We were not able to calculate rates by diabetes type because this question was not asked in NHIS during the study period.

Joinpoint Trend Analysis can identify statistically significant changes in linear trends direction or magnitude and calculates the annual percentage change APC for each identified time segment 7.

To assess for a linear trend over the 7-year period from to , we selected a maximum of zero joinpoints. In , there were an estimated 16, U. adult ED visits for DKA where the patient was not admitted to an inpatient unit Table 1.

In that same year, there were , adult admissions to inpatient settings in U. hospitals for DKA. Of all adults with DKA, in , From to , there was an increase in the proportion of adults with DKA having public health insurance i. In both years, the Northeast region had the lowest number of DKA episodes, while the South had the highest Table 1.

AMA, left against medical advice; NA, not available; SNF, skilled nursing facility. Overall, U. adult nonadmitted ED visit rates for DKA doubled from to from 1.

In the inpatient setting, DKA rates increased In the inpatient setting, all age-groups experienced a significant increase in DKA rates from to However, the 18—year-old age-group had the highest rates Patients with Medicare or Medicaid as the primary payer had the highest DKA event rates in both the ED and inpatient settings.

An increasing trend in DKA rates in the ED setting was seen for all but the uninsured. In the inpatient setting, Medicaid and private insurance had increasing DKA trends. DKA rates increased in the ED setting in the Midwest and West, and in the inpatient setting, rates increased in the Midwest, South, and West.

In , DKA rates were highest in the South Age-adjusted DKA ED and hospitalization rates per 1, adults with diagnosed diabetes, — Numerator data are from the NEDS and NIS.

Dots are observed annual values. The lines are modeled using Joinpoint Trend Analysis Software. The U. In , there were an estimated 2, U. adult ED visits for HHS where the patient was not admitted to an inpatient unit Table 2.

In that same year, there were 24, adult admissions to inpatient settings in U. hospitals for HHS. Overall, in , Similar to DKA, from to , there was an increase in the proportion of adults with HHS having public health insurance i.

In , Approximately a quarter were discharged to skilled nursing facilities, other short-term hospitals, or with home care. From to , the proportion dying in the hospital setting declined from 1.

The West region had the lowest number of HHS episodes, while the South had the highest Table 2. adult nonadmitted ED visit rates for HHS more than doubled from to from 1. In the inpatient setting, HHS rates increased The significantly increasing trend was seen in both ED and inpatient settings for both men and women and for all age-groups Supplementary Tables 3 and 4.

Patients with Medicare or Medicaid as the primary payer had the highest HHS event rates in the inpatient setting but varied in the ED setting.

The privately insured had consistently lower HHS rates in both settings. An increasing trend in HHS rates in the ED setting was seen for patients with public sponsored programs but not for privately insured or uninsured patients. Only the population with private insurance as the primary payer had a significant increase in HHS events in the inpatient setting.

HHS rates increased in the ED setting in all regions of the country, and in the inpatient setting, rates increased in all but the Northeast region. In , inpatient HHS rates were highest in the South Age-adjusted HHS ED and hospitalization rates per 10, adults with diagnosed diabetes, — The contribution of each complication DKA and HHS across patient care settings ED and inpatient and diabetes type type 1 and type 2 is important to assess.

Nonadmitted DKA and HHS cases in the ED setting comprised the remaining cases of hyperglycemic crises. For DKA, the burden was highest among young adults 18—44 years of age and for adults with type 1 diabetes.

Trends varied by subpopulations, but overall, DKA and HHS rates increased from to overall and for all age-groups, in both men and women, in both ED and inpatient settings, and in most regions of the country. The APCs were similar and higher in the ED setting for both conditions, but the burden was higher in the inpatient setting.

This comprehensive report adds to the growing literature on the resurgence of diabetes complications in the U. We show that both DKA and HHS are increasing overall and in all age categories and both sexes. By including the ED setting in our analysis, we also refute the hypothesis that a change in the threshold for hyperglycemic crises warranting hospital admissions may be contributing to this finding 3.

In fact, we also saw an increase in ED visit rates for DKA and HHS in patients who were treated and not admitted to hospitals. In England, a different trend in DKA hospitalizations was described for people with type 1 diabetes. Zhong et al. Although we are not able to differentiate trends by diabetes type, we see a rapid increase in DKA starting in in the U.

The demographic characteristics of patients with hyperglycemic crises in this analysis were similar to those in other studies. For example, although often perceived as a complication of type 1 diabetes, we found that roughly one-third of DKA cases were patients with type 2 diabetes and that DKA was predominantly a problem among young adults 11 , We also found HHS occurring mostly in patients with type 2 diabetes who were older However, HHS event rates were highest in the youngest age category.

HHS is recognized as an emerging issue in children and young adults Other studies using NIS have found similar increases in hyperglycemic crisis events but use different denominators 15 , Our study is unique in that we report rates by the population with diagnosed diabetes, which accounts for changes in diabetes epidemiology over time.

In addition, we report estimates for HHS, which does not appear in the literature. The etiology of the resurgence of DKA and HHS is unknown, but numerous causes are possible. Infections are a precipitating cause of both DKA and HHS 2 , with urinary tract infections and pneumonia being specifically associated with HHS Overall, infections requiring hospitalization among adults with diabetes did not increase from to The incidence of skin and soft tissue infections, including cellulitis, foot infections, and osteomyelitis, increased among adults with diabetes from to , but pneumonia rates remained flat over time Noninfectious acute events, such myocardial infarction and stroke, are also precipitating causes of HHS During the same time period that DKA and HHS rates increased, myocardial infarction and stroke increased among adults with diabetes in younger age-groups 8.

It is possible that these acute events led to increased rates of HHS in the younger population, but again, it does not explain the increases in both conditions in all age-groups.

The frequency of alcohol and drug abuse is high among patients presenting with DKA 20 , A recent meta-analysis of survey data reported on the increased prevalence of alcohol use and binge drinking over the past 10—15 years Middle-aged and older adults were most affected.

This would not explain the sharp increase in DKA event rates in young adults nor the increase in HHS event rates. However, cannabis use has also been found to increase the risk of DKA among patients with type 1 diabetes These patients were younger with a mean age of 31 years and were more likely to be male.

It cannot be determined with these data whether and to what degree alcohol and drug abuse are contributing to the increase in hyperglycemic events. Sodium—glucose cotransporter 2 inhibitors, approved for treatment of type 2 diabetes, have been found to increase the risk of DKA.

In May , the U. Food and Drug Administration issued a drug safety communication about this risk 24 and subsequently added a warning to the drug label Food and Drug Administration has not approved the use of sodium—glucose cotransporter 2 inhibitors in patients with type 1 diabetes.

Although this drug class was first approved in March and therefore was not responsible for the initial increase in DKA episodes, it is worthy of further monitoring. Insulin omission is the most common cause of DKA in young patients with type 1 diabetes 2.

Causes of poor adherence to insulin are varied and include eating disorders, fear of weight gain, psychological distress, and fear of hypoglycemia Insulin prices tripled from to in the U. How much these changes have contributed to the upward trend in hyperglycemic crises is unknown.

The data on primary payers, however, do not consistently support this theory. Uninsured patients accounted for only a small proportion of the total cases of hyperglycemic crisis events and their event rates were flat from to The majority of the hyperglycemic crisis events and the highest event rates occurred in the population with Medicare or Medicaid as the primary payer, with increasing rates from to in the Medicaid population for both DKA and HHS except for hospitalizations for HHS.

Medicaid beneficiaries with diabetes generally self-report having poorer health and more comorbidities than other insured populations Despite the fact that Medicaid either pays for most medications or requires a nominal copayment, out-of-pocket costs for medications and medical care are still a concern and, in some cases, may lead to insulin rationing 29 , Medicare beneficiaries with prescription drug coverage i.

We found that hyperglycemic crisis event rates increased in the Medicare population in the ED setting and increased in the inpatient setting for the privately insured, albeit at rates much lower than the Medicare or Medicaid insured population. Ketosis-prone diabetes has been described since the s and has an atypical presentation, including severe hyperglycemia and ketoacidosis with no precipitating cause 31 , These patients usually have obesity with a strong family history of type 2 diabetes and often recover after treatment without the need of further insulin treatment.

Though these patients may be contributing to the overall numbers of patients classified in the ED and inpatient settings as having DKA, we did not find evidence in the literature that this disease variant is increasing in the population, and thus it is unlikely to explain the increasing trend of hyperglycemic crises.

This study had a number of limitations. First, because of the inability to differentiate diabetes type in the NHIS survey data, we were not able to report trends in DKA and HHS rates by diabetes type.

Although consistent with the literature, even the hyperglycemic crisis event numbers by diabetes type were subject to misclassification based on coding errors. Second, NEDS and NIS are event-level data, not patient-level data.

We do not know how many of these events were readmissions versus new events, which would falsely increase population-based rates, especially in certain subpopulations at higher risk for recurrence 33 , Third, the case definitions of DKA and HHS were based on first-listed ICDCM codes.

Events may have been misclassified by coding errors or missed if the hyperglycemic code was not selected as the primary diagnosis Application of strict diagnostic criteria may also be lacking, as evidenced by the low mortality disposition of those admissions with HHS, which is inconsistent with case studies However, these potential misclassifications and missed events were not likely to affect trends in rates over time.

Fourth, we did not consider the comorbid diagnoses of DKA and HHS. Pasquel et al. Fifth, the duration of diabetes is unknown using these data sets, so we were not able to stratify the analysis by newly diagnosed versus established disease.

Sixth, from to , there was a decline in the total number of hospital admissions with the primary code of This code does not differentiate hyper- from hypoglycemic coma, which may be the reason for the decreased use.

If these cases were instead classified as DKA or HHS, this coding change would boost DKA and HHS rates but not enough to fully explain the increasing trend. Finally, although NEDS and NIS are the largest administrative data sets for U.

ED visits and inpatient admissions and are nationally representative, federal hospitals are not included in the sample, which excludes a small segment of the U. In summary, we report an overall increase in DKA and HHS event rates among adults in both the ED and inpatient settings in the U.

from to The increase is occurring in all age-groups, in both sexes, and in all regions of the country, suggesting that widespread societal factors may be influencing this trend. Although these data do not provide a definitive etiology, we do see some subpopulations at high risk of acute diabetic complications such as young adults, people with lower income, and people with public insurance as the primary payer.

A deeper dive into data with more clinical, economic, and community characteristics may help determine the specific factors leading to these trends, which may, in turn, help determine preventive measures for these life-threatening, yet avoidable, complications of diabetes.

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. is partially supported by a National Institutes of Health grant from the National Institute of General Medical Sciences 1KGMA1.

Duality of Interest. No potential conflicts of interest relevant to this article were reported. Author Contributions. developed the study concept, performed analysis and interpretation of the data, and drafted the manuscript.

analyzed the data. participated in the study design and interpretation of the data and critically revised the manuscript. is the guarantor of this work and, as such, had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Hyperglycemia is a very common presentation in the emergency department. The presentation of hyperglycemia ranges from asymptomatic and benign in patients with mild to moderate uncomplicated hyperglycemia to life-threatening, i.

diabetic ketoacidosis DKA or hyperosmolar hyperglycemic state HHS. DKA and HHS represent a spectrum of complications from diabetes and differ mainly in the level of hyperglycemia, extent of dehydration and presence and degree of ketoacidosis.

Each condition revolves around insulin deficiency, either absolute or relative. In these patients, a thorough history and physical examination should be performed with a focus on trying to identify a precipitating cause of the hyperglycemia. In patients with an incidental finding of mild to moderate hyperglycemia or those with minor symptoms, little else may be necessary beyond anticipatory guidance and proper follow up.

If present, a basic metabolic profile should be obtained to exclude an increased gap metabolic acidosis. Many of these patients will need intravenous administration of saline. In a patient who is more ill appearing, hemodynamically unstable and those suspected of having DKA or HHS the following should be instituted:.

Attention should be paid to the volume status of the patient. Be cautious of high volume crystalloid infusion in patients with congestive heart failure or chronic renal failure.

Patients with mild hyperglycemia may in fact be asymptomatic. At this time, patients may present with a variety of complaints including;. These symptoms will be highly variable from patient to patient.

Some will also develop tachycardia, dizziness, lightheadedness and weakness as a result of dehydration and electrolyte imbalance. As the degree of hyperglycemia progresses leading to marked volume depletion, electrolyte disturbance, acidosis, ketosis, etc.

additional symptoms may be seen including:. DKA and HHS are the most serious, acute metabolic complications of diabetes, but other differentials include dietary indiscretion and new onset or uncontrolled diabetes. Both disease entities originate from a reduction in insulin and an increase in counter-regulatory stress hormones.

In the emergency department, hyperglycemia is most often seen as a complication of diabetes both types 1 and 2. Hyperglycemia is defined as:.

Is a state of absolute insulin deficiency, hyperglycemia, anion gap acidosis, and dehydration. It is classically seen in Type 1 diabetics and typically occurs in younger people. The most common causes are infections, disruption of insulin therapy, or as the presentation of new onset diabetes.

Is a state of hyperglycemia, hyperosmolarity, and dehydration without significant ketoacidosis. It is typically seen in Type 2 diabetics, has a higher mortality rate compared to DKA, and occurs in older patients. It most commonly occurs in poorly controlled Type 2 diabetics with an underlying infection.

A number of other conditions can affect diabetic patients resulting in an increase in counter regulatory hormones and hyperglycemia, some of which can precipitate DKA or HHS. In patients suspected of having DKA or HHS, additional tests should be obtained:.

Diagnosing DKA or HHS is done at the bedside with a high clinical suspicion based on the patient history, physical exam, and initial laboratory findings. The following table presents the diagnostic criteria for DKA and HHS. Table 1. Diagnostic Criteria for Diabetic Ketoacidosis DKA and Hyperosmolar Hyperglycemic State.

Arterial pH. Mild: 7. Moderate: 7. Mild: Moderate: Urine ketones. Serum ketones. Anion gap. Mental Status. Mild: Alert. In patients with an uncomplicated presentation associated with mild — moderate hyperglycemia, often no urgent treatment is required, however in some cases, patients may requires intravenous fluids.

Treatment for DKA and HHS is centered around correcting the intravascular volume depletion, management of electrolyte abnormalities, insulin replacement therapy and identification of and treatment of any underlying precipitants.

Historically, isotonic saline 0.

Management and Disposition of Adults with New-Onset Hyperglycemia without Hyperglycemic Emergency

Aside from these emergent conditions, hyperglycemia in ED patients is frequently unrecognized, undertreated, and poorly communicated 1. In , ED patients are at particularly high risk for diabetes, and many adults that present to the ED meet American Diabetes Association ADA criteria for diabetes screening 6—8.

While screening for diabetes is not routine in the ED, random glucose levels are frequently obtained 9. In ordering and interpreting the results of these tests, emergency physicians are optimally positioned to identify patients at high risk for diabetes and initiate treatment when indicated.

After evaluating the patient for hyperglycemic emergencies, the ED clinician should focus on the distinction between type 1 and type 2 diabetes and the identification of complicating factors such as infection and dehydration.

Most patients with type 2 diabetes present without symptoms, and their hyperglycemia will be an incidental finding Symptomatic hyperglycemic patients may require an evaluation for electrolyte derangements, DKA, and hyperosmolarity with:.

A new diagnosis of diabetes can be made in the ED using the ADA criteria. These criteria include 8 :. In ED patients without a hyperglycemic emergency in whom other dangerous etiologies have been excluded, the next step is to distinguish the type of diabetes.

Patients with type 1 or autoimmune-mediated diabetes are at higher risk for poor short-term outcomes. Critically, failure to identify a patient with type 1 diabetes and initiate appropriate treatment can lead to rapid development of life-threatening hyperglycemic emergencies Key Point : Have a high suspicion for type 1 diabetes in patients presenting with marked weight loss, ketonuria, a personal or family history of autoimmune disorders, and no family history of type 2 diabetes Table 1.

Clinical features at presentation that help to distinguish type 1 and type 2 diabetes table reprinted from BMJ;m Recommendations for treatment to specifically address uncomplicated hyperglycemia in the ED setting are limited 14,21, Emergency Medicine EM physicians vary greatly in their thresholds for hyperglycemia management and comfort with initiation of outpatient treatment While there is evidence to suggest that discharge with elevated glucose does not result in short-term adverse events, this study does not adequately address safety in the subpopulation of newly diagnosed diabetics This protocol was shown to be safe and showed improved glycemic control at 4 weeks The most important component is establishing rapid follow-up with a physician who can coordinate diabetes education and provide outpatient therapy.

For severe elevations and inability to follow up, admission may be required. Rapid acting insulin will only drop the blood glucose for several hours without other therapies, and then the patient is right back where they started. Continue on for a great breakdown on disposition!

Generally, the following categories can help determine disposition of the stable diabetic patient. Category 1 : If type 1 diabetes is suspected, consider either admission to the hospital for further evaluation or an ED endocrinology consult for assistance with discharge planning.

Category 2 : Hyperglycemic patients with a clinical picture consistent with undiagnosed type 2 diabetes i. obesity, family history of type 2 diabetes, dyslipidemia , without an apparent underlying cause of their hyperglycemia.

However, these patients are very likely to be diagnosed with diabetes on confirmatory testing and should be directed to follow-up with a primary care provider PCP for further evaluation Currently, there is no minimum random plasma glucose level at which the ADA recommends screening for diabetes 8.

At the time of discharge, consider initiating metformin mg once a day with the plan to increase to twice daily in one week 12, If prescriptions are provided, the patient will need close follow-up with endocrinology or their PCP for reassessment and ongoing medication adjustments.

After initial resuscitation and ruling out hyperglycemic emergencies or an underlying cause, these patients are often stable for discharge. Most published guidelines focus on initiation of treatment in the outpatient setting but fail to address the management of severely hyperglycemic patients in the ED who are otherwise stable 12,14,31, To our knowledge, there is no consensus on initiation of anti-diabetes medications for patients with severe hyperglycemia in the ED 14,22,24, Patients with new-onset severe hyperglycemia with an unstable social situation or no access to follow-up care should be admitted for initiation of therapy In well-resourced settings with close follow-up and availability of diabetic education, there is limited evidence that shows both safety and efficacy with initiation of outpatient therapy on discharge from the ED 21,24, As such, we believe it is reasonable to discharge a reliable patient with a plan for initiation of long-acting insulin therapy 21, Initiation of outpatient long-acting insulin therapy from the ED has several requirements to be successful:.

If the above requirements are met, consider starting long-acting insulin such as glargine 10 units daily or glargine 0. Patient education on the administration of insulin can be performed at the bedside with the assistance of training pens, visual aids, and video instructions 34— If your institution has diabetes educators that provide training for hospitalized patients, consider asking for their assistance It may be beneficial to give the patient their first dose of long-acting insulin while still in the ED Consider the timing of administration of the long-acting insulin you give, as changing the timing of the dose will require careful attention.

The patient should also be discharged with a glucometer and other materials for glucose monitoring, with the plan to check their blood sugar at least twice per day The patient should be educated on the signs and symptoms of hypoglycemia and understand how to self-rescue should hypoglycemia occur Case 1 : The patient is discharged home with primary care follow-up for further testing, as he is asymptomatic and does not meet ADA criteria for diagnosis of diabetes.

Case 2 : The patient meets criteria for diagnosis of diabetes. Your email address will not be published. Save my name, email, and website in this browser for the next time I comment. Notify me of follow-up comments by email. Notify me of new posts by email.

We are actively recruiting both new topics and authors. This project is rolling and you can submit an idea or write-up at any time! Contact us at editors emdocs. Wheezing and Stridor. Popular Recent Comments FROM THE ARCHIVES emDOCs Podcast — Episode The Metric That Really Matters ABG Versus VBG in the Emergency Department ECG Pointers: Recurrent and Refractory Torsades de Pointes emDOCs Podcast — Episode GLP-1 Agonist Complications Policy Playbook: Labor Actions and Unionization in Healthcare EMDOCS IN YOUR MAILBOX Enter your email address to receive notifications of new posts by email.

emDocs is licensed under a Creative Commons Attribution 4. Powered by Gomalthemes. Toggle navigation. Menu All Content.

Previous Post. Next Post. Management and Disposition of Adults with New-Onset Hyperglycemia without Hyperglycemic Emergency. Jul 5th, Xavier Schwartz categories: practice updates. Introduction Emergency physicians are well versed in the management of acute diabetic emergencies such as hypoglycemia, diabetic ketoacidosis DKA , and hyperglycemic hyperosmolar state HHS.

Does this hyperglycemic patient have a new diagnosis of diabetes? History Commonly, hyperglycemic patients present with polyuria, polydipsia, weight loss, and vision changes Hyperglycemic patients require three separate assessments: Evaluation for hyperglycemic emergencies diabetic ketoacidosis and hyperglycemic hyperosmolar state Evaluation of the etiology for the hyperglycemia such as infection, ischemia stroke, pulmonary embolism, acute coronary syndrome , medications steroids , malignancy, and pregnancy.

Evaluation for type 1 versus type 2 diabetes. Key elements of the history include duration of symptoms and personal or family history of diabetes or autoimmune disorders. A recent history of marked weight loss and other severe symptoms in a short period of time should raise suspicion for type 1 diabetes Physical Exam General Appearance: normal or thin body habitus should heighten suspicion for type 1 8.

Cardiovascular and mucous membranes: hyperglycemia related dehydration can result in dry mucous membranes and tachycardia. Respiratory: tachypnea suggestive of DKA and signs of pulmonary infection Neurologic: altered mentation suggestive of HHS , and decreased sensation in the distal extremities indicating neuropathy secondary to chronic hyperglycemia Skin: acanthosis nigricans, signs of infection, wounds on the feet, and decreased skin turgor Laboratory Evaluation Most patients with type 2 diabetes present without symptoms, and their hyperglycemia will be an incidental finding Symptomatic hyperglycemic patients may require an evaluation for electrolyte derangements, DKA, and hyperosmolarity with: Point of care glucose Basic metabolic panel Complete blood count Urinalysis Urine pregnancy test for women of childbearing age Venous blood gas Serum osmolality Beta-hydroxybutyrate A new diagnosis of diabetes can be made in the ED using the ADA criteria.

Disposition Generally, the following categories can help determine disposition of the stable diabetic patient. Initiation of outpatient long-acting insulin therapy from the ED has several requirements to be successful: Hospital nursing, emergency department administration, endocrine, PCP support Availability of targeted patient education for safe administration of insulin and glucose monitoring Availability of materials to provide the patient on discharge glucometer and test strips Communication and coordination of care with outpatient providers If the above requirements are met, consider starting long-acting insulin such as glargine 10 units daily or glargine 0.

Take-Home Points Type 1 autoimmune diabetes can present in adults. Consider type 1 diabetes in adult patients with hyperglycemia and severe weight loss, polyuria, or polydipsia. This mandates an ED endocrinology consult or hospital admission.

Disposition of these patients will vary by practice environment. Consider initiation of long-acting glargine at 0. Case Conclusions Case 1 : The patient is discharged home with primary care follow-up for further testing, as he is asymptomatic and does not meet ADA criteria for diagnosis of diabetes.

Limited communication and management of emergency department hyperglycemia in hospitalized patients. J Hosp Med. Treatment of inpatient hyperglycemia beginning in the emergency department: A randomized trial using insulins aspart and detemir compared with usual care.

Impact of a Subcutaneous Insulin Protocol in the Emergency Department: Rush Emergency Department Hyperglycemia Intervention REDHI.

J Emerg Med. Are lower fasting plasma glucose levels at diagnosis of type 2 diabetes associated with improved outcomes? Much ink has been spilled over diabetic ketoacidosis DKA , and the related entity hyperosmolar hyperglycemic state HHS , but many patients present with hyperglycemia without meeting criteria for these clinical entities.

How do you treat them? If so, how much? How do you plan their disposition? As always, our ED population is at higher risk than most. Despite these numbers, many emergency physicians find it hard to get fired up over hyperglycemia.

One quasi-experimental study from an academic centre in Chicago [7] used an ED rapid acting insulin protocol with q2h glucose checks to see if it would have an impact on the degree of hyperglycemia, ED and hospital length of stay LOS , and adverse events including hypoglycemia.

However, it did not affect ED LOS and the rate of hypoglycemia was 7. Insulin is effective, although not without risk! Driver et al. asked if glucose level at time of discharge from the ED was associated with 7-day ED revisits or hospitalization [8].

This was still the case even with a dichotomous analysis at a threshold of More recently, a Canadian study by Yan et al. After a regression analysis, they found 5 risk factors and 2 protective factors all statistically significant , summarized here:.

These are potentially modifiable precipitants with some combination of counselling with educational interventions and, maybe most importantly, close follow-up just like the Driver study suggested. Emergency Department Visits for Adults With Diabetes, Statistical Brief Poor glycemic control in diabetic patients seeking care in the ED.

The American Journal of Emergency Medicine , 24 6 , — Trends in emergency department visit rates for hypoglycemia and hyperglycemic crisis among adults with diabetes, United States, PLoS ONE , 10 8 , — Multicenter survey of emergency physician management and referral for hyperglycemia.

Hyperglycemic Emergencies in Adults - Diabetes Canada World-Class Emergency Medicine: To provide outstanding compassionate emergency care through practice-changing Hyperflycemia and innovative Hyperglycemia and emergency room visits education. Accessed Hyperylycemia 24, Introduction Diabetic ketoacidosis DKA and hyperosmolar hyperglycemic state HHS are diabetes emergencies with overlapping features. Estimated Risk for Undiagnosed Diabetes in the Emergency Department: A Multicenter Survey. National Institute on Drug Abuse.
Which diabetes andd you should continue wnd which bisits you ekergency temporarily stop. Note : Diabetic nephropathy holistic approaches Hyprrglycemia diagnosis and treatment Hyperglycemia and emergency room visits diabetic ketoacidosis DKA in adults and in Cognitive enhancement strategies share general principles, there are significant differences in Hypsrglycemia application, largely related to the eergency risk of life-threatening cerebral Diabetic nephropathy holistic approaches with DKA in Wmergency and adolescents. The specific issues related to treatment of DKA in children and adolescents are addressed in the Type 1 Diabetes in Children and Adolescents chapter, p. Diabetic ketoacidosis DKA and hyperosmolar hyperglycemic state HHS are diabetes emergencies with overlapping features. With insulin deficiency, hyperglycemia causes urinary losses of water and electrolytes sodium, potassium, chloride and the resultant extracellular fluid volume ECFV depletion. Potassium is shifted out of cells, and ketoacidosis occurs as a result of elevated glucagon levels and insulin deficiency in the case of type 1 diabetes. There may also be high catecholamine levels suppressing insulin release in the case of type 2 diabetes.

Hyperglycemia and emergency room visits -

Accessed February 24, Frequency and phenotype of type 1 diabetes in the first six decades of life: a cross-sectional, genetically stratified survival analysis from UK Biobank. Lancet Diabetes Endocrinol.

Pharmacologic Approaches to Glycemic Treatment. Distinguishing between type 1 and type 2 diabetes. m Barker JM. Clinical review: Type 1 diabetes-associated autoimmunity: natural history, genetic associations, and screening.

J Clin Endocrinol Metab. Differentiation of Diabetes by Pathophysiology, Natural History, and Prognosis. Family history and prevalence of diabetes in the U.

population: the 6-year results from the National Health and Nutrition Examination Survey Characteristics of newly diagnosed adults with type 1 diabetes in the UK and evolution of glycaemic control, body mass index and Charlson comorbidity index over the first 5 years after diagnosis.

Prim Care Diabetes. Can clinical features be used to differentiate type 1 from type 2 diabetes? A systematic review of the literature. BMJ Open. Synergy to reduce emergency department visits for uncontrolled hyperglycemia. Diabetes Educ. Discharge Glucose Is Not Associated With Short-Term Adverse Outcomes in Emergency Department Patients With Moderate to Severe Hyperglycemia.

Ann Emerg Med. Multicenter Survey of Emergency Physician Management and Referral for Hyperglycemia. The Synergy To Enable Glycemic Control Following Emergency Department Discharge Program For Adults With Type 2 Diabetes: STEP-Diabetes.

Endocr Pract Off J Am Coll Endocrinol Am Assoc Clin Endocrinol. OR Charfen MA, Ipp E, Kaji AH, Saleh T, Qazi MF, Lewis RJ. Detection of Undiagnosed Diabetes and Prediabetic States in High-risk Emergency Department Patients. x Bowen ME, Xuan L, Lingvay I, Halm EA.

Random Blood Glucose: A Robust Risk Factor For Type 2 Diabetes. Random plasma glucose in serendipitous screening for glucose intolerance: screening for impaired glucose tolerance study 2.

J Gen Intern Med. Age, BMI, and race are less important than random plasma glucose in identifying risk of glucose intolerance: the Screening for Impaired Glucose Tolerance Study SIGT 5. McGraw-Hill Education; Metformin in the treatment of adults with type 2 diabetes mellitus — UpToDate.

Management of Hyperglycemia and Diabetes in the Emergency Department. Curr Diab Rep. Accessed March 4, Safe and Simple Emergency Department Discharge Therapy for Patients with Type 2 Diabetes Mellitus and Severe Hyperglycemia. Endocr Pract. ORR Boston Medical Center.

How to Inject Insulin with a Pen and Pen Needle. Accessed April 21, How to Use an Insulin Pen — Mayo Clinic Patient Education. Cleveland Clinic. Successful patient diabetes education in the emergency department. Leave a Reply Cancel reply Your email address will not be published.

emDOCs subscribes to the Free Open Access Meducation FOAMed initiative. Our goal is to inform the global EM community with timely and high yield content about what providers like YOU are seeing and doing everyday in your local ED. Algorithm of the month Wheezing and Stridor. Popular Recent Comments.

EMDOCS IN YOUR MAILBOX Enter your email address to receive notifications of new posts by email. Featured Articles. emDOCs Podcast — Episode practice updates. ABG Versus VBG in the Emergency Dep ECG Pointers: Recurrent and Refract emDOCs Podcast — Episode GLP Policy Playbook: Labor Actions and Blood Pressure Management in Neurol In the Literature.

Journal Feed Weekly Wrap-Up In the Literature. em 3am. The SRU is the "Shock Resuscitation Unit. In , a total of 16 million ED visits were reported with diabetes listed as a diagnosis, with , of these being for hyperglycemic crisis 1. In this post, we will explore the evaluation and treatment of various hyperglycemic etiologies in the ED through a series of clinical scenarios.

A 43 year-old woman presents to the ED with nausea, and vomiting. According to EMS, she has a past medical history of HTN, HLD, and T1DM. A finger stick glucose in triage reveals an elevated glucose of Physical exam reveals an ill, but non-toxic appearing female.

Abdominal exam is soft with diffuse tenderness with palpation, but no rebound tenderness or guarding. A 71 year-old male presents to the ED via EMS from a long term care facility with altered mental status.

According to EMS the patient has a history of COPD, HTN, HLD, and T2DM. Physical exam reveals an individual that responds to tactile stimulation only, is unable to answer orientation questions, has extremely dry mucous membranes, and is tachycardic with regular rhythm.

One of most important parts of evaluating any patient presenting to the ED with suspected hyperglycemic emergency is looking for a precipitating cause. Death directly from DKA and HHS is relatively uncommon; instead, patients are much more likely to die from a precipitating event. In patients presenting in DKA or HHS, the 5 main precipitating causes can be identified as.

Two of the most common hyperglycemic emergencies associated with diabetes mellitus are diabetic ketoacidosis DKA and hyperglycemic hyperosmolar state HHS.

Although both result in severe hyperglycemia, the underlying pathophysiology and clinical presentation can be vastly different.

DKA is a state of near absolute insulin deficiency. It typically occurs in Type 1 diabetics, but also occurs in type 2 diabetes under conditions of extreme stress such as serious infection, trauma, cardiovascular or other emergencies.

VBG gives you pH without sticking for an ABG. Renal panel. The major ketone present in the body in DKA is beta-hydroxybutyrate, but the traditional nitroprusside reaction test used in many laboratories does not detect it.

Acetone and acetoacetate are typically detected with high sensitivity, but these are present in much lower levels than beta-hydroxybutyrate. In DKA, the ratio of beta-hydroxybutyrate to acetoacetate changes in response to the increased ketones from a ratio of to as much as Therefore, urine ketones can underestimate the severity of ketoacidosis.

If available, serum ketones detecting beta-hydroxybutyrate should be used to detect ketones in patients with possible DKA.

Differentiating between DKA and HHS is important for many reasons. However, the foundation of treatment for both hyperglycemic emergencies is similar and include:. Initial fluid therapy is aimed at expansion of intravascular, interstitial, and intracellular volume, all of which are decreased in DKA and HHS.

Subsequent choice of fluid replacement depends on patient hemodynamics, volume status, and electrolytes. The caveat to the use of isotonic saline is that since these ADA recommendations, several studies have found benefit in using a balanced crystalloid like LR or Plasmalyte instead of NS to avoid hyperchloremic metabolic acidosis.

Hyperglycemic emergencies cause total-body potassium depletion. However, hyperkalemia on laboratory studies is not uncommon. To prevent hypokalemia, potassium replacement should be initiated after serum levels fall below the upper level of normal.

Rarely, DKA patients may present with hypokalemia. How much insulin is to be given and by which route has been the subject of much debate. Goyal et al prospectively compared the utility of the initial insulin bolus in patients. In this study, both groups were similar at baseline and received the same amount of IV fluids, as well as insulin infusions.

There was no significant difference in the incidence of hypoglycemia, rate of serum glucose change, anion gap change, or length of ED or hospital stay. Most of the current studies have focused specifically on bolus vs.

In addition to improving patient outcomes, this could equate to significant cost savings for the health care system. The team hopes this knowledge can be used to develop targeted interventions for patients who are at higher risk of returning to hospital for hyperglycemia.

They are planning future studies to look at what factors contribute to a patient being at higher risk of adverse outcomes and what interventions are most effective in preventing them.

News story republished with permission from Lawson Health Research Institute. COVID Updates Important information for patients, families and visitors to read before coming to our sites. Read more.

Case 1: A year-old Hyperglycemix presents to the Emergency Hypwrglycemia ED with atypical chest pain: sharp, left-sided, worst e,ergency movement, Top thermogenic ingredients after Diabetic nephropathy holistic approaches ibuprofen. Diabetic nephropathy holistic approaches denies nausea, diaphoresis, orom, pleuritic pain, hemoptysis, lightheadedness, worsening with exertion. He has a past medical history of well-controlled hypertension and no significant family history. Physical exam reveals normal vital signs, pain with range of motion of the left shoulder, and tenderness to palpation over the left pectoral muscle and anterior shoulder. His cardiac workup reveals an unremarkable ECG and two negative troponins.

Author: Malak

1 thoughts on “Hyperglycemia and emergency room visits

Leave a comment

Yours email will be published. Important fields a marked *

Design by ThemesDNA.com