🩸 DIABETIC EMERGENCIES – INDIA

COMPREHENSIVE DUAL-LEVEL CARE PROTOCOL

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PRIMARY CARE → SECONDARY CARE

📋 For Doctors Only | Not for Public Use

Covers: Diabetic Ketoacidosis (DKA) | Hyperosmolar Hyperglycaemic State (HHS) | Hypoglycaemia

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🏥 LEVEL OF CARE OVERVIEW

Procedure/Action	Primary Care	Secondary/Tertiary Care
Blood glucose measurement	✅	✅
Recognition of DKA/HHS/Hypoglycemia	✅	✅
Hypoglycemia treatment (IV Dextrose)	✅	✅
Initial IV fluid resuscitation	✅	✅
First dose of IV/IM insulin	✅ (if trained)	✅
Potassium measurement	⚠️ Limited	✅
Arterial Blood Gas (ABG)	❌	✅
Serum ketones / Urine ketones	⚠️ (Urine dipstick)	✅
Continuous insulin infusion	❌	✅
Intensive electrolyte monitoring	❌	✅
ICU-level care	❌	✅
Cerebral edema management	❌	✅
Hemodialysis (if needed)	❌	✅

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⏱️ CRITICAL TIME TARGETS

Milestone	Target Time
Check blood glucose	≤ 5 min
Treat hypoglycemia	Immediate
Establish IV access	≤ 10 min
Start IV fluids (DKA/HHS)	≤ 15 min
Identify precipitant	Within 1 hour
Start insulin (DKA)	After initial fluids + K⁺ check
Transfer to higher centre (if needed)	ASAP after stabilization

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📖 DEFINITIONS & DIAGNOSTIC CRITERIA

Comparison Table: DKA vs HHS vs Hypoglycemia

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DKA Severity Classification

Anion Gap Calculation

Anion Gap = Na⁺ - (Cl⁻ + HCO₃⁻)

Normal: 8-12 mEq/L

DKA: Usually > 12-14 mEq/L

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Serum Osmolality Calculation

Effective Osmolality = 2 × Na⁺ + (Glucose mg/dL ÷ 18)

Normal: 275-295 mOsm/kg

HHS: > 320 mOsm/kg

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🟢 PART 1 — PRIMARY CARE

Goal: Recognise → Check Glucose → Treat Hypoglycemia immediately → Start Fluids for DKA/HHS → TRANSFER

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1️⃣ INITIAL ASSESSMENT

Check Blood Glucose in ANY Patient With:

Presentation	Check Glucose?
Altered mental status / Confusion	✅ Mandatory
Unexplained drowsiness / Coma	✅ Mandatory
Seizures	✅ Mandatory
Excessive thirst / Polyuria	✅ Yes
Nausea / Vomiting in diabetic	✅ Yes
Abdominal pain in diabetic	✅ Yes
Rapid / Deep breathing (Kussmaul)	✅ Yes
Fruity breath odor	✅ Yes
Any unwell diabetic patient	✅ Yes
Sweating, tremors, palpitations	✅ Yes (hypoglycemia)

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2️⃣ RECOGNITION

Quick Diagnostic Table

Finding	Likely Diagnosis	Immediate Action
Glucose < 70 mg/dL	HYPOGLYCEMIA	Treat immediately (Dextrose)
Glucose > 250 + Acidotic breathing + Ketones	DKA	IV Fluids → Transfer
Glucose > 600 + Severe dehydration + Altered sensorium	HHS	IV Fluids → Transfer
Glucose > 250-600 + Mild symptoms	Hyperglycemia (may be evolving DKA/HHS)	IV Fluids, Monitor, Consider transfer

Clinical Features Comparison

Feature	Hypoglycemia	DKA	HHS
Onset	Minutes	Hours to 1-2 days	Days to weeks
Sweating	✅ Common	❌ No	❌ No
Tremors / Palpitations	✅ Common	❌ No	❌ No
Hunger	✅ Common	❌ Anorexia	❌ Anorexia
Nausea / Vomiting	Rare	✅ Common	⚠️ Less common
Abdominal pain	❌ No	✅ Common	Rare
Kussmaul breathing	❌ No	✅ Yes (deep, rapid)	❌ No
Fruity breath (acetone)	❌ No	✅ Yes	❌ No
Dehydration	❌ No	✅ Moderate-Severe	✅ Severe
Altered sensorium	⚠️ If severe	⚠️ If severe	✅ Usually present
Skin	Cold, clammy	Warm, dry	Warm, dry

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3️⃣ HYPOGLYCEMIA – PRIMARY CARE MANAGEMENT

Definition

Category	Blood Glucose
Level 1 (Alert)	< 70 mg/dL (3.9 mmol/L)
Level 2 (Clinically significant)	< 54 mg/dL (3.0 mmol/L)
Level 3 (Severe)	Any level with altered mental status requiring assistance

Common Causes of Hypoglycaemia

Cause	Details
Insulin overdose	Wrong dose, timing, or type
Sulfonylurea overdose	Glimepiride, Glibenclamide, Gliclazide
Missed or delayed meal	Most common cause
Excess physical activity	Without adjusting insulin/food
Alcohol intake	Impairs gluconeogenesis
Renal impairment	Reduced insulin/drug clearance
Accidental/intentional overdose	Self-harm, medication error

Immediate Treatment Protocol

Patient Status	Treatment	Dose
Conscious, able to swallow	Oral glucose (tablets, juice, sugar)	15-20 g glucose
	Examples: 4 glucose tablets, 150 mL fruit juice, 3-4 teaspoons sugar in water
Conscious but not swallowing safely	Glucose gel applied to buccal mucosa	15-20 g
Unconscious / Unable to swallow	IV Dextrose 25%	50-100 mL IV push
	OR IV Dextrose 50%	25-50 mL IV push
No IV access	IM Glucagon (if available)	1 mg IM

25% Dextrose Preparation (if only D5W or D10W available)

Available Solution	How to Make 25% Dextrose
50% Dextrose	Dilute 1:1 with sterile water
25% Dextrose	Use directly
10% Dextrose	Give larger volume (150-250 mL)

Post-Treatment Protocol

Step	Action	Timing
1	Recheck blood glucose	15 minutes after treatment
2	If still < 70 mg/dL	Repeat dextrose bolus
3	If glucose > 70 mg/dL and conscious	Give complex carbohydrate snack/meal
4	Start D10% maintenance infusion	If unable to eat or sulfonylurea-induced
5	Monitor glucose	Every 30-60 min for 2-4 hours

Sulfonylurea-Induced Hypoglycemia – Special Considerations

Key Point	Details
Prolonged hypoglycemia risk	Sulfonylureas have long half-life (12-24+ hours)
Recurrence common	May need prolonged D10% infusion
Monitoring duration	At least 24-48 hours
Octreotide	Consider at higher centre (inhibits insulin release)
Hospital admission	Mandatory for all sulfonylurea-induced hypoglycemia

Transfer Criteria for Hypoglycaemia

Indication	Transfer?
Sulfonylurea-induced hypoglycemia	✅ Yes (always admit)
Recurrent hypoglycemia despite treatment	✅ Yes
Intentional overdose / Self-harm	✅ Yes
Unknown cause of hypoglycemia	✅ Yes
Elderly with comorbidities	✅ Yes
Neurological deficit after recovery	✅ Yes
Mild episode in known diabetic, resolved, able to eat	❌ May observe

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4️⃣ DKA – PRIMARY CARE MANAGEMENT

Recognition at Primary Care

Clinical Feature	Present?
Known diabetic (especially Type 1) or new-onset diabetes	☐
Blood glucose > 250 mg/dL	☐
Nausea / Vomiting	☐
Abdominal pain	☐
Kussmaul breathing (deep, rapid)	☐
Fruity (acetone) breath	☐
Dehydration (dry mucosa, decreased skin turgor)	☐
Altered sensorium	☐
Urine ketones positive (if dipstick available)	☐

If glucose > 250 + acidotic breathing + ketones → Assume DKA

Identify the Precipitant (5 I's)

Precipitant	Check For
Infection	Pneumonia, UTI, skin infection, sepsis (most common - 40-50%)
Insulin omission	Non-compliance, inadequate dose, pump failure
Infarction	MI, stroke (may be silent in diabetics)
Intoxication	Alcohol, drugs
Iatrogenic	Steroids, thiazides, SGLT2 inhibitors (euglycemic DKA)
Pregnancy	New-onset or poor control
New-onset diabetes	First presentation (especially T1DM)

Immediate Actions at Primary Care

Step	Action	Details
1	Airway & Breathing	Protect airway if GCS < 8
2	IV Access	2 large-bore cannulas (16-18G)
3	Blood Glucose	Document initial value
4	Urine Ketones	Dipstick if available
5	Start IV Fluids	Normal Saline 0.9% – 1L in first hour (15-20 mL/kg)
6	Oxygen	If SpO₂ < 94%
7	Do NOT give insulin yet	Need K⁺ level first (at higher centre)
8	Identify precipitant	Look for infection, check for MI
9	TRANSFER	Urgent transfer to higher centre

Fluid Resuscitation at Primary Care

Phase	Fluid	Volume	Rate
Initial (Hour 1)	Normal Saline 0.9%	1-1.5 L	15-20 mL/kg/hr
If available, continue	Normal Saline 0.9%	500 mL-1L	Over 1-2 hours

📌 Priority is FLUIDS, not insulin at primary care level

Should You Give Insulin at Primary Care?

Scenario	Give Insulin?	Rationale
K⁺ unknown (no lab available)	⚠️ Caution	Insulin can cause fatal hypokalemia
K⁺ available and > 3.3 mEq/L	✅ May give	Safe to start insulin
K⁺ < 3.3 mEq/L	⛔ Do NOT give	Replace K⁺ first
Transfer possible within 1-2 hours	❌ Defer to higher centre	Start fluids; insulin at receiving hospital
Remote area, long transfer time, K⁺ unknown	⚠️ Consider 0.05-0.1 U/kg IM	Discuss with higher centre; suboptimal but may be needed

If Insulin Must Be Given at Primary Care (Resource-Limited Setting)

Route	Dose	Notes
IM Regular Insulin	0.1 U/kg	If no IV pump available
SC Regular Insulin	0.1 U/kg	Less reliable in dehydrated patient

⚠️ This is suboptimal – IV insulin infusion at higher centre is standard of care

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5️⃣ HHS – PRIMARY CARE MANAGEMENT

Recognition at Primary Care

Clinical Feature	Present?
Elderly patient with Type 2 DM	☐
Blood glucose > 600 mg/dL	☐
Severe dehydration (may be 8-12 L deficit)	☐
Altered mental status (confusion, drowsiness, coma)	☐
Absence of Kussmaul breathing	☐
Absence of significant ketones	☐
Often has precipitating illness (infection, MI, stroke)	☐

Key Differences from DKA (Important for Recognition)

Feature	DKA	HHS
Breathing	Kussmaul (deep, rapid)	Normal or shallow
Breath odor	Fruity (acetone)	Usually normal
Ketones	Positive	Negative or trace
Dehydration	Moderate-Severe	Very Severe
Mental status	Variable	Usually altered
Patient type	Often Type 1, younger	Elderly, Type 2

Immediate Actions at Primary Care

Step	Action	Details
1	Airway & Breathing	Protect airway; GCS often low
2	IV Access	2 large-bore cannulas
3	Blood Glucose	Document (often > 600 mg/dL)
4	Start IV Fluids	Normal Saline 0.9% – 1L in first hour
5	Second liter	1L over next 1-2 hours
6	Avoid insulin initially	Fluids first; insulin at higher centre
7	Identify precipitant	Infection, MI, stroke common
8	TRANSFER URGENTLY	HHS has higher mortality than DKA

Fluid Resuscitation in HHS

Key Point	Details
Fluid deficit	Often 8-12 liters (more than DKA)
Initial fluid	Normal Saline 0.9%
Rate	1-1.5 L in first hour
Caution in elderly	Watch for fluid overload (cardiac comorbidities)
Priority	FLUIDS >> Insulin (fluids alone will lower glucose)

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6️⃣ TRANSFER PROTOCOL

Transfer Urgency

Condition	Transfer Urgency
Hypoglycemia (resolved, eating, not sulfonylurea)	May observe at primary level
Hypoglycemia (sulfonylurea-induced)	✅ ADMIT (minimum 24-48 hrs observation)
DKA – Mild	✅ Transfer (can manage at district hospital with labs)
DKA – Moderate/Severe	✅ URGENT Transfer to ICU-capable facility
HHS (all cases)	✅ URGENT Transfer to ICU-capable facility

Pre-Transfer Checklist

Item	Done?
Blood glucose documented	☐
IV access × 2 secured	☐
IV fluids started (volume given documented)	☐
Vitals documented (BP, HR, RR, SpO₂, GCS, Temperature)	☐
Urine ketones checked (if available)	☐
Any insulin given documented (time, dose, route)	☐
Precipitant identified/suspected	☐
Diabetes medications documented	☐
Allergies documented	☐
Receiving hospital pre-alerted	☐

During Transport

Requirement	Details
Monitoring	Blood glucose every 30-60 min, vitals every 15 min
IV fluids	Continue NS infusion
Glucose source	Carry dextrose for rebound hypoglycemia
Airway	Be prepared for aspiration (nausea, vomiting, altered GCS)
Oxygen	If SpO₂ < 94%

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🔵 PART 2 — SECONDARY/TERTIARY CARE

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7️⃣ EMERGENCY DEPARTMENT PROTOCOL

Initial Assessment

Action	Target Time
Confirm diagnosis (DKA vs HHS vs Mixed)	≤ 15 min
IV access (if not done)	Immediate
Blood glucose	Immediate
VBG / ABG	≤ 15 min
Serum electrolytes (Na, K, Cl, HCO₃)	≤ 30 min
Serum ketones (β-hydroxybutyrate)	≤ 30 min
Renal function (Cr, BUN)	≤ 30 min
CBC	≤ 30 min
Urine analysis	≤ 30 min
ECG	≤ 15 min (look for MI, hyperkalemia)
CXR	≤ 1 hour (look for infection)

Investigations Checklist

Investigation	Purpose	Done?
Blood glucose	Confirm hyperglycemia	☐
VBG / ABG	pH, HCO₃, pCO₂	☐
Serum Na⁺, K⁺, Cl⁻	Electrolyte disturbance	☐
Serum bicarbonate	Acidosis severity	☐
Anion gap	Confirm high AG acidosis	☐
Serum ketones (β-OHB)	Ketosis severity	☐
Serum osmolality	HHS diagnosis	☐
Creatinine, BUN	Renal function	☐
CBC	Infection (WBC may be elevated in DKA without infection)	☐
Urinalysis	Ketones, infection	☐
Blood cultures	If infection suspected	☐
ECG	Hyperkalemia, MI	☐
CXR	Pneumonia	☐
HbA1c	Baseline control (can do later)	☐

Corrected Sodium Calculation

Corrected Na⁺ = Measured Na⁺ + [1.6 × (Glucose - 100) / 100]

Or simplified: Add 1.6 mEq/L to Na⁺ for every 100 mg/dL glucose above 100

Measured Na⁺	Glucose (mg/dL)	Corrected Na⁺
130	500	130 + (1.6 × 4) = 136.4
125	800	125 + (1.6 × 7) = 136.2
120	1,000	120 + (1.6 × 9) = 134.4

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8️⃣ DKA – COMPREHENSIVE MANAGEMENT

Treatment Pillars

Pillar	Goal
1. Fluids	Restore intravascular volume; improve tissue perfusion
2. Insulin	Suppress ketogenesis; lower glucose
3. Potassium	Prevent life-threatening hypokalemia
4. Treat Precipitant	Infection, MI, etc.
5. Monitor	Frequent glucose, electrolytes, pH

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PILLAR 1: FLUID RESUSCITATION

Fluid Protocol

Phase	Time	Fluid	Volume/Rate
1	Hour 0-1	Normal Saline 0.9%	1-1.5 L (15-20 mL/kg)
2	Hours 1-4	NS 0.9% (or 0.45% if corrected Na high)	250-500 mL/hr
3	Hours 4+	NS 0.9% or 0.45% based on Na⁺	150-250 mL/hr
4	When glucose < 200 mg/dL	Add D5 to fluids (D5NS or D5 0.45% NS)	Continue 150-250 mL/hr

Fluid Selection Based on Corrected Sodium

Corrected Na⁺	Fluid After Initial Bolus
High (> 145 mEq/L)	0.45% Normal Saline
Normal (135-145 mEq/L)	0.45% or 0.9% Normal Saline
Low (< 135 mEq/L)	0.9% Normal Saline

When to Add Dextrose

Blood Glucose	Action
> 200 mg/dL	Continue NS (no dextrose)
< 200 mg/dL	Switch to D5NS or D5 0.45% NS
Target	Maintain glucose 150-200 mg/dL until resolution

📌 Adding dextrose allows continued insulin infusion to clear ketones while preventing hypoglycemia

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PILLAR 2: INSULIN THERAPY

Pre-Insulin Checklist

Criterion	Requirement	Met?
K⁺ level known	✅ Must check before insulin	☐
K⁺ > 3.3 mEq/L	✅ Required to start insulin	☐
Initial fluid bolus given	✅ At least 1 L NS	☐
IV access secure	✅ Functional line	☐

⛔ If K⁺ < 3.3 mEq/L → Give potassium FIRST; hold insulin until K⁺ > 3.3

Insulin Protocol

Route	Regimen	Dose
IV Infusion (Preferred)	Regular Insulin	0.1 U/kg/hr (continuous infusion)
	OR Bolus + Infusion	0.1 U/kg bolus, then 0.1 U/kg/hr
Alternative (no pump)	Regular Insulin IM	0.1 U/kg IM every hour
Low-dose protocol	If K⁺ borderline or pediatric	0.05 U/kg/hr

Insulin Infusion Preparation

Preparation	Concentration
50 units Regular Insulin in 50 mL NS	1 unit/mL
100 units Regular Insulin in 100 mL NS	1 unit/mL

Weight (kg)	0.1 U/kg/hr	Infusion Rate (1 U/mL)
50	5 U/hr	5 mL/hr
60	6 U/hr	6 mL/hr
70	7 U/hr	7 mL/hr
80	8 U/hr	8 mL/hr

Insulin Titration

Blood Glucose	Insulin Adjustment
Falling > 70 mg/dL/hr	Reduce infusion by 50%
Falling 50-70 mg/dL/hr	Maintain current rate
Falling < 50 mg/dL/hr	Increase infusion by 1-2 U/hr
Glucose < 200 mg/dL	Add D5 to fluids; may reduce insulin to 0.02-0.05 U/kg/hr
Target glucose	150-200 mg/dL until DKA resolved

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PILLAR 3: POTASSIUM REPLACEMENT

Potassium Protocol (CRITICAL)

Serum K⁺ (mEq/L)	Action	K⁺ Replacement
< 3.3	⛔ HOLD INSULIN	20-40 mEq/hr IV until K⁺ > 3.3
3.3-5.3	Start/continue insulin	20-30 mEq in each liter of IV fluid
> 5.3	Start/continue insulin	Do not give K⁺; recheck in 2 hours

Potassium Replacement Details

K⁺ Level	K⁺ Dose	Maximum Rate
< 3.3 mEq/L	40 mEq/L of fluid	20 mEq/hr (10-20 mEq/hr via peripheral line)
3.3-4.0 mEq/L	30 mEq/L of fluid	20 mEq/hr
4.0-5.3 mEq/L	20 mEq/L of fluid	10-20 mEq/hr
> 5.3 mEq/L	Hold potassium	Recheck in 2 hours

Potassium Forms

Form	Content	Notes
KCl (Potassium Chloride)	20 mEq/15 mL (common)	Most commonly used
KCl	40 mEq/20 mL	Concentrated; needs dilution
K-Phos (Potassium Phosphate)	Variable	Use if PO₄ < 1 mg/dL

⚠️ Caution: Maximum K⁺ via peripheral IV is 10-20 mEq/hr (to prevent vein irritation); higher rates need central line

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BICARBONATE THERAPY

When to Give Bicarbonate

pH	Bicarbonate Therapy
≥ 6.9	⛔ NOT recommended
< 6.9	May consider

Bicarbonate Protocol (if pH < 6.9)

Indication	Dose	Administration
pH < 6.9	50-100 mEq NaHCO₃	In 200-400 mL sterile water over 1-2 hours
Add potassium	20-40 mEq KCl	To the bicarbonate solution
Repeat pH	In 2 hours	If still < 6.9, may repeat

📌 Routine bicarbonate is NOT recommended – may worsen hypokalaemia and paradoxical CNS acidosis

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MONITORING PROTOCOL

Frequency of Monitoring

Parameter	Frequency
Blood glucose	Every 1 hour
Serum K⁺, Na⁺, HCO₃	Every 2-4 hours
VBG / ABG (pH)	Every 2-4 hours (until pH > 7.3)
Anion gap	Every 2-4 hours
Vital signs	Every 1-2 hours
Urine output	Every 1 hour
Mental status	Every 1-2 hours
Serum ketones	Every 4-6 hours (or POC as available)

DKA Resolution Criteria

Criterion	Target Value
Blood glucose	< 200 mg/dL
Serum bicarbonate	≥ 15 mEq/L
Venous pH	> 7.3
Anion gap	≤ 12 mEq/L
Patient	Alert, tolerating oral intake

All criteria should be met before transitioning to subcutaneous insulin

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TRANSITION TO SUBCUTANEOUS INSULIN

When to Transition

Criteria for Transition	Met?
DKA resolved (all resolution criteria met)	☐
Patient able to eat	☐
No nausea/vomiting	☐
Mentally alert	☐

Transition Protocol

Step	Action
1	Calculate total daily dose (TDD) of insulin
2	Give SC basal insulin (50% of TDD)
3	Continue IV insulin for 2 hours after SC dose
4	Then discontinue IV insulin
5	Give SC rapid-acting insulin with meals (50% of TDD divided between meals)

Insulin Dose Calculation

Scenario	Total Daily Dose (TDD)
New-onset diabetes	0.5-0.7 U/kg/day
Known diabetes (previous dose known)	Resume previous TDD (adjust if needed)
From IV insulin rate	IV rate × 24 × 0.8 (e.g., 2 U/hr → 2 × 24 × 0.8 = 38 U/day)

Example Transition

TDD	Basal Insulin (50%)	Bolus Insulin (50%)
40 U/day	20 U Glargine/Detemir at bedtime	~6-7 U with each meal (breakfast, lunch, dinner)

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9️⃣ HHS – COMPREHENSIVE MANAGEMENT

Key Differences from DKA Management

Aspect	DKA	HHS
Fluid deficit	4-6 L	8-12 L
Initial fluid rate	15-20 mL/kg/hr	15-20 mL/kg/hr (may need more)
Insulin timing	After initial fluid + K⁺	After significant fluid resuscitation (1-2 L)
Insulin dose	0.1 U/kg/hr	Lower: 0.02-0.05 U/kg/hr initially
Glucose target	150-200 mg/dL	250-300 mg/dL initially
Osmolality monitoring	Less critical	Critical – avoid rapid change
Cerebral edema risk	Children mainly	Lower (but osmolar shifts can cause neurological harm)

HHS Fluid Protocol

Phase	Time	Fluid	Volume/Rate
1	Hour 0-1	Normal Saline 0.9%	1-1.5 L
2	Hours 1-2	NS 0.9%	1 L
3	Hours 2+	NS 0.9% or 0.45% (based on corrected Na⁺)	250-500 mL/hr
4	When glucose < 300 mg/dL	Add D5 to fluids	150-250 mL/hr

HHS Insulin Protocol

Step	Action
1	Start fluids first – fluids alone will drop glucose
2	After 1-2 L NS and K⁺ > 3.3, start low-dose insulin
3	Insulin: 0.02-0.05 U/kg/hr (lower than DKA)
4	Target glucose drop: 50-75 mg/dL/hr
5	Target initial glucose: 250-300 mg/dL (slower correction)
6	Add D5 when glucose < 300 mg/dL

HHS Monitoring

Parameter	Frequency	Target
Blood glucose	Every 1 hour	Drop 50-75 mg/dL/hr
Serum osmolality	Every 2-4 hours	Drop 3-8 mOsm/kg/hr
Na⁺, K⁺	Every 2-4 hours	Na⁺: avoid rapid rise; K⁺: 4-5 mEq/L
Mental status	Continuous	Expect slow improvement
Urine output	Hourly	Target > 0.5 mL/kg/hr

HHS Resolution Criteria

Criterion	Target
Glucose	< 300 mg/dL
Osmolality	< 315 mOsm/kg
Mental status	Back to baseline
Hemodynamically stable	Yes

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🔟 HYPOGLYCEMIA – SECONDARY CARE MANAGEMENT

Continued Treatment Protocol

Scenario	Management
Resolved, eating	Observe; prevent recurrence
Recurrent episodes	D10% infusion at 100-200 mL/hr; titrate to maintain glucose 100-180 mg/dL
Sulfonylurea-induced	Prolonged D10% infusion (may need 24-48+ hrs)
Refractory to dextrose	Consider Octreotide

Octreotide for Sulfonylurea-Induced Hypoglycemia

Drug	Dose	Route	Frequency
Octreotide	50-100 μg	SC	Every 8-12 hours

Octreotide inhibits insulin release and reduces dextrose requirement

Monitoring in Severe/Prolonged Hypoglycaemia

Parameter	Frequency
Blood glucose	Every 30-60 min (more frequent if unstable)
Mental status	Continuous
Electrolytes	Every 4-6 hours
D10% infusion rate	Titrate to glucose 100-180 mg/dL

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1️⃣1️⃣ CEREBRAL EDEMA

Risk Factors for Cerebral Oedema

Risk Factor
Pediatric patients (especially < 5 years)
New-onset diabetes
Longer duration of symptoms before treatment
Severe acidosis (pH < 7.1)
Severe hypocapnia (low pCO₂)
High BUN at presentation
Rapid IV fluid administration
Rapid glucose drop (> 100 mg/dL/hr)
Bicarbonate administration
Failure of Na⁺ to rise as glucose falls

Warning Signs of Cerebral Edema

Sign	Present?
Headache (new or worsening)	☐
Vomiting (after initial improvement)	☐
Altered mental status (confusion, irritability, drowsiness)	☐
Bradycardia	☐
Hypertension	☐
Irregular respirations	☐
Pupillary changes	☐
Posturing (decorticate/decerebrate)	☐
Seizures	☐

⚠️ If any warning signs → Suspect cerebral oedema → Act immediately

Cerebral Edema Management

Step	Action
1	Reduce IV fluid rate by 50%
2	Elevate head of bed to 30°
3	Mannitol 0.5-1 g/kg IV over 15-20 min
4	OR Hypertonic saline (3%) 2.5-5 mL/kg over 10-15 min
5	Intubate if GCS < 8 or airway at risk
6	Avoid hyperventilation (target PaCO₂ 35-40)
7	Urgent CT brain (after stabilization)
8	Neurosurgery consult

Mannitol vs Hypertonic Saline

Agent	Dose	Notes
Mannitol 20%	0.5-1 g/kg IV over 15-20 min	May repeat in 30-60 min if needed; max 2-3 doses
Hypertonic Saline 3%	2.5-5 mL/kg IV over 10-15 min	Preferred if hypovolemic; can repeat

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1️⃣2️⃣ COMPLICATIONS OF DKA/HHS

🇮🇳 Mucormycosis – India-Specific Alert

Key Point
Increased incidence during COVID-19 pandemic
Risk factors: DKA, corticosteroid use, uncontrolled diabetes
Presentation: Facial pain, nasal discharge, black eschar, orbital involvement
Diagnosis: MRI, biopsy, KOH mount
Treatment: Liposomal Amphotericin B + Urgent surgical debridement
Specialist referral: ENT, Ophthalmology, Infectious Disease

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1️⃣3️⃣ PRECIPITANT MANAGEMENT

Common Precipitants and Management

Precipitant	Investigation	Treatment
Infection (40-50%)	CBC, Cultures (blood, urine, sputum), CXR	Empiric antibiotics per sepsis protocol
Insulin omission	History	Patient education; address barriers
New-onset diabetes	HbA1c, GAD antibodies, C-peptide	Diabetes education; initiate insulin
Myocardial infarction	ECG, Troponin	Cardiology consult; ACS protocol
Stroke	CT brain	Stroke protocol
Pancreatitis	Amylase, Lipase, CT abdomen	NPO, IV fluids, supportive
Drugs (steroids, thiazides)	Medication review	Adjust/stop offending drug
SGLT2 inhibitors	Medication history	Stop SGLT2 inhibitor (can cause euglycemic DKA)
Pregnancy	β-hCG	Obstetric consult
Alcohol/substance use	History, toxicology screen	Supportive; address underlying issue

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1️⃣4️⃣ DISCHARGE PLANNING

Discharge Criteria

Criterion	Met?
DKA/HHS resolved (all biochemical criteria met)	☐
Eating and drinking normally	☐
On stable SC insulin regimen for ≥ 12-24 hours	☐
Glucose reasonably controlled (100-250 mg/dL)	☐
Precipitant identified and addressed	☐
No significant electrolyte abnormality	☐
Patient/caregiver educated	☐
Follow-up appointment scheduled	☐

Discharge Medications

By Diabetes Type & Scenario

Type 1 DM (or New-Onset DM Presenting with DKA)

Category	Medication	Dose	Notes
Basal Insulin	Glargine (Lantus)	50% of TDD	Once daily (bedtime or morning)
	OR Detemir (Levemir)	50% of TDD	Once or twice daily
	OR Degludec (Tresiba)	50% of TDD	Once daily (any time)
	OR NPH	50% of TDD	Twice daily (if long-acting unavailable)
Bolus Insulin	Aspart (NovoRapid)	50% of TDD ÷ 3 meals	Before each meal
	OR Lispro (Humalog)	50% of TDD ÷ 3 meals	Before each meal
	OR Glulisine (Apidra)	50% of TDD ÷ 3 meals	Before each meal
	OR Regular Insulin	50% of TDD ÷ 3 meals	30 min before meals (if rapid-acting unavailable)
Oral agents	⛔ NOT applicable	—	Type 1 DM requires lifelong insulin

📌 Type 1 DM = Lifelong insulin; Never discharge on oral agents alone

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Type 2 DM – After DKA

Scenario	Discharge Regimen
Severe DKA / Poor prior control (HbA1c > 10%)	Basal-bolus insulin (as above); review in clinic for possible oral agent addition
Moderate DKA / Moderate control (HbA1c 8-10%)	Basal insulin ± oral agents (see below)
Mild DKA / Good prior control (HbA1c < 8%)	May resume prior oral agents + add basal insulin if needed
Precipitant resolved (e.g., infection treated)	May transition to oral agents earlier

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Type 2 DM – After HHS

Recommendation
Most patients need insulin at discharge (at least basal insulin)
HHS often indicates significant beta-cell failure
May add oral agents later as outpatient once stable
Close follow-up essential

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Oral Antidiabetic Agents – When to Resume

Drug Class	When to Resume	Cautions
Metformin	When ALL criteria met (see below)	Risk of lactic acidosis if resumed too early
Sulfonylureas (Glimepiride, Gliclazide, Glibenclamide)	Once eating regularly; glucose stable	Risk of hypoglycemia; avoid if poor oral intake
DPP-4 Inhibitors (Sitagliptin, Vildagliptin, Linagliptin)	Can resume once eating and stable	Dose-adjust for renal function (except Linagliptin)
GLP-1 Receptor Agonists (Liraglutide, Semaglutide, Dulaglutide)	Once eating, no nausea/vomiting, stable	May delay gastric emptying; caution in dehydration
SGLT2 Inhibitors (Dapagliflozin, Empagliflozin, Canagliflozin)	⛔ STOP / DO NOT RESUME if caused euglycemic DKA	Discuss with endocrinologist before any future use
Thiazolidinediones (Pioglitazone)	Can resume if no heart failure, no fluid overload	Risk of fluid retention
Acarbose / Voglibose	Can resume once eating normally	GI side effects

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Metformin – Specific Criteria for Resumption

Criterion	Requirement
eGFR	> 30 mL/min/1.73m² (preferably > 45)
No AKI	Creatinine returned to baseline
Eating and drinking normally	Yes
No dehydration	Adequately hydrated
No acute illness	Infection treated; hemodynamically stable
No hypoxia / Tissue hypoperfusion	Normal lactate, no shock
Timing	Usually wait 48-72 hours after resolution of DKA/HHS

⛔ Do NOT resume Metformin if:

• eGFR < 30 mL/min/1.73m²
• Ongoing AKI
• Patient still unwell / septic
• Recent contrast exposure (wait 48 hrs and check creatinine)

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SGLT2 Inhibitors – Important Guidance

Scenario	Action
Euglycemic DKA caused by SGLT2i	⛔ Permanently discontinue that agent
DKA with high glucose (not euglycemic)	⛔ Stop; may cautiously restart later with endocrinology guidance
Patient has heart failure / CKD (strong indication for SGLT2i)	Discuss risk-benefit with endocrinologist/cardiologist
Future use	Only with careful patient selection, education on sick-day rules, and avoiding dehydration

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SGLT2i Sick Day Rules (If Patient Previously on SGLT2i)

Rule
Stop SGLT2 inhibitor during acute illness
Stop if unable to eat or drink
Stop before surgery (at least 3 days before)
Stop if dehydrated or fasting
Resume only when fully recovered and eating normally

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Complete Discharge Medication Table (Corrected)

Basal Insulin	✅ Required	✅ Usually required	⚠️ May be required
Bolus Insulin	✅ Required	⚠️ Often required initially	❌ May not be needed
Metformin	❌ Not applicable	⚠️ Resume when criteria met	✅ Resume when criteria met
Sulfonylurea	❌ Not applicable	⚠️ Caution; consider reducing dose	⚠️ May resume
DPP-4 Inhibitor	❌ Not applicable	✅ Can resume	✅ Can resume
GLP-1 RA	❌ Not applicable	⚠️ Resume when tolerating oral intake	✅ Can resume
SGLT2 Inhibitor	❌ Not applicable	⛔ Stop; reassess later	⛔ Stop; reassess later
Pioglitazone	❌ Not applicable	⚠️ Avoid if fluid overload/HF	⚠️ May resume

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Insulin Dose Calculation for Discharge

Method	Calculation
From IV insulin rate	TDD = IV rate (U/hr) × 24 × 0.8
Example	If on 2 U/hr IV → TDD = 2 × 24 × 0.8 = 38 units/day
New-onset / Unknown	Start with 0.5-0.6 U/kg/day
Elderly / Renal impairment	Start with 0.3-0.4 U/kg/day

TDD	Basal (50%)	Bolus (50% ÷ 3 meals)
30 U	15 U at bedtime	5 U with each meal
40 U	20 U at bedtime	6-7 U with each meal
50 U	25 U at bedtime	8 U with each meal
60 U	30 U at bedtime	10 U with each meal

Patient Education Before Discharge

Topic	Covered?
Sick day rules	☐
When to check for ketones	☐
Never skip insulin (even if not eating)	☐
Signs of hyperglycemia / DKA	☐
Signs of hypoglycemia	☐
Importance of hydration	☐
When to seek medical attention	☐
Medication administration	☐
Glucometer use	☐
Follow-up appointment	☐

Sick Day Rules

Rule
Never stop insulin – may need more, not less
Check blood glucose every 2-4 hours
Check urine/blood ketones if glucose > 250 mg/dL
Stay hydrated – drink water, clear fluids
Seek medical help if: vomiting, unable to eat/drink, ketones positive, glucose persistently > 300, feeling confused

Follow-up

Appointment	Timing
Diabetes clinic / Endocrinology	Within 1-2 weeks
Primary care	Within 1 week
Dietitian	Within 1-2 weeks
Diabetes educator	Before discharge or within 1 week

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📌 QUICK REFERENCE CARDS

🔴 PRIMARY CARE – DIABETIC EMERGENCY CARD

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🔵 DKA MANAGEMENT QUICK REFERENCE

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🔵 HHS MANAGEMENT QUICK REFERENCE

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💊 INSULIN INFUSION QUICK REFERENCE

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💉 HYPOGLYCEMIA QUICK REFERENCE

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⚠️ CRITICAL WARNINGS

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🧮 CALCULATIONS QUICK REFERENCE

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📋 DKA RESOLUTION CRITERIA

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📚 ABBREVIATIONS

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📖 REFERENCES

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Document Version: 1.0

Disclaimer: This protocol provides general guidance based on available evidence. Clinical judgment must always be exercised. Local protocols may vary. Pediatric management has specific considerations not fully covered in this adult-focused protocol.

India-Specific Notes:

• High prevalence of T2DM with DKA (not just T1DM)
• Consider tropical infections as precipitants
• Mucormycosis risk (especially post-COVID era)
• SGLT2 inhibitor use increasing – consider euglycemic DKA