Teaching Pearls:

• Emergent clinical manifestations of diabetes includes diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS).
• DKA Manifestations
  • Presence of ketones
  • Glucose usually less than 700
  • Can present with N/V and abdominal pain
  • Acute presentation
• HHS Manifestations
  • Lack of ketones present
  • Glucose usually greater than 700
  • Usually present with neurological changes including stupor and coma.
  • Subacute presentation
• A small subset of DKA can present with euglycemic DKA.
  • Patients present with presence of ketones and a normal to near normal glucose levels.
  • More commonly seen in patients with poor PO intake, recent insulin use prior to ED arrival, and pregnancy state
  • Management is geared towards to decreasing ketones.
  • Other causes of anion gap are ruled out, with presence of ketones.
• Management
  • Similar for DKA (including euglycemic) and HHS
  • Fluid resuscitation as many of these patients are hypovolemic.
  • Insulin gtt for moderate to severe manifestations
    • 0.1units/kg bolus followed by 0.1units/kg/hour or:
    • start at 0.14units/kg/hour without a bolus