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Diabetic Emergencies: Hypoglycemia, DKA, and HHS Recognition [ Medical Education ](https://mdster.com/blog?category=medical-education) Diabetic Emergencies: Hypoglycemia, DKA, and HHS Recognition ============================================================== A rapid outpatient approach to glucose checks, ketones, rescue therapy, and urgent transfer [ MDster Editorial Team ](https://mdster.com/about) · Aug 26, 2026 · 5 min read · 194 [ Reviewed by Dr. Ali Ragab, MBBCH, MSc, MCAI ](https://mdster.com/medical-reviewers/dr-ali-ragab) [Editorial Policy](https://mdster.com/editorial-policy) | [Corrections Policy](https://mdster.com/corrections) [ Board Review ](https://mdster.com/blog?tag=board-review) [ Family Medicine ](https://mdster.com/blog?tag=family-medicine) [ Diabetic Emergencies ](https://mdster.com/blog?tag=diabetic-emergencies) [ Urgent Care ](https://mdster.com/blog?tag=urgent-care) [ Hypoglycemia ](https://mdster.com/blog?tag=hypoglycemia) [ DKA and HHS ](https://mdster.com/blog?tag=dka-and-hhs) ![Diabetic Emergencies: Hypoglycemia, DKA, and HHS Recognition](https://mdster.com/storage/blog/images/diabetic-emergencies-hypoglycemia-dka-and-hhs-recognition.jpg) Share this article Share this post On this page 1. [ Start With Glucose and Mental Status ](#start-with-glucose-and-mental-status) 2. [ Hypoglycemia: Treat Before You Investigate ](#hypoglycemia-treat-before-you-investigate) 3. [ Match treatment to swallowing ability ](#match-treatment-to-swallowing-ability) 4. [ When to use glucagon ](#when-to-use-glucagon) 5. [ Recognizing DKA and HHS ](#recognizing-dka-and-hhs) 6. [ Ketones change the decision ](#ketones-change-the-decision) 7. [ Urgent Transfer: Do Not Manage the Crisis in Clinic ](#urgent-transfer-do-not-manage-the-crisis-in-clinic) 8. [ Key Takeaways ](#key-takeaways) 9. [ Conclusion ](#conclusion) 10. [ Frequently Asked Questions ](#blog-faqs) 11. [ References ](#references-heading) On this page 1. [ Start With Glucose and Mental Status ](#start-with-glucose-and-mental-status) 2. [ Hypoglycemia: Treat Before You Investigate ](#hypoglycemia-treat-before-you-investigate) 3. [ Match treatment to swallowing ability ](#match-treatment-to-swallowing-ability) 4. [ When to use glucagon ](#when-to-use-glucagon) 5. [ Recognizing DKA and HHS ](#recognizing-dka-and-hhs) 6. [ Ketones change the decision ](#ketones-change-the-decision) 7. [ Urgent Transfer: Do Not Manage the Crisis in Clinic ](#urgent-transfer-do-not-manage-the-crisis-in-clinic) 8. [ Key Takeaways ](#key-takeaways) 9. [ Conclusion ](#conclusion) 10. [ Frequently Asked Questions ](#blog-faqs) 11. [ References ](#references-heading) A diaphoretic patient becomes confused in your waiting room. Another arrives vomiting with a glucose of 185 mg/dL while taking an SGLT2 inhibitor. Both may have life-threatening diabetic emergencies, and neither diagnosis should wait for a complete history. In urgent care, think in this order: **check glucose, assess mental status, treat immediate threats, look for ketones and dehydration, then arrange the correct disposition**. This approach reflects guidance current through August 2026. Start With Glucose and Mental Status ------------------------------------ Obtain a point-of-care glucose immediately in any patient with confusion, seizure, syncope, weakness, diaphoresis, tachycardia, or unexplained behavioral change. Do not attribute altered mentation to intoxication, dementia, or infection before excluding hypoglycemia. Simultaneously assess: - Airway protection and ability to swallow - Vital signs, perfusion, and orthostasis - Medication exposure, especially insulin and sulfonylureas - Vomiting, polyuria, polydipsia, and reduced intake - Mucous membranes, capillary refill, and urine output Hypoglycemia: Treat Before You Investigate ------------------------------------------ Glucose below 70 mg/dL requires action; glucose below 54 mg/dL represents clinically significant hypoglycemia. Severe, or level 3, hypoglycemia is defined by altered functioning requiring assistance, regardless of the measured value. [\[1\]](#cite-1 "Reference [1]") ### Match treatment to swallowing ability For an alert patient who can swallow safely: 1. Give approximately 15 g of fast-acting glucose. 2. Recheck glucose after 15 minutes. 3. Repeat treatment until glucose exceeds 70 mg/dL and symptoms resolve. 4. Follow with a meal or longer-acting carbohydrate when appropriate. Avoid chocolate or other high-fat foods initially because absorption is delayed. For an obtunded, seizing, or aspiration-risk patient, give no oral intake. Administer IV dextrose according to the local emergency protocol when vascular access is available, titrating to neurologic recovery and repeating glucose checks every 15 minutes. [\[1\]](#cite-1 "Reference [1]") ### When to use glucagon Use glucagon when severe hypoglycemia prevents oral treatment and IV access is unavailable or delayed. Ready-to-use injectable and intranasal products are preferred over formulations requiring reconstitution; follow the device-specific labeled dose. Glucagon depends on hepatic glycogen. Its effect may be limited after prolonged fasting, severe malnutrition, alcohol-associated hypoglycemia, or advanced liver disease. Place the recovering patient laterally because nausea and vomiting may occur. > **Clinical Pearl:** Glucagon buys time; it does not establish disposition. Recheck glucose, give carbohydrate after awakening, identify the cause, and anticipate recurrence. Recognizing DKA and HHS ----------------------- Do not diagnose a hyperglycemic crisis from glucose alone. DKA is a disorder of **ketosis and acidosis**, while HHS is dominated by **hyperosmolality and profound dehydration**. FeatureDKAHHSTempoHours to daysDays to weeksTypical cluesVomiting, abdominal pain, Kussmaul respirationsMarked dehydration, focal deficits, confusionKetonesProminentAbsent or mildGlucoseVariable; may be below 200 mg/dLUsually at least 600 mg/dL Current adult DKA criteria require diabetes or glucose at least 200 mg/dL, β-hydroxybutyrate at least 3 mmol/L or urine ketones at least 2+, and pH below 7.3 or bicarbonate below 18 mmol/L. HHS requires glucose at least 600 mg/dL, hyperosmolality, minimal ketonemia, and no substantial acidosis. [\[2\]](#cite-2 "Reference [2]") ### Ketones change the decision Measure blood β-hydroxybutyrate when available. Urine nitroprusside testing detects acetoacetate rather than β-hydroxybutyrate, so it may underestimate early DKA and remain positive during recovery. Remember **euglycemic DKA**, particularly with SGLT2 inhibitors, pregnancy, fasting, or recent insulin administration. A relatively modest glucose must not reassure you when vomiting, tachypnea, abdominal pain, or ketones are present. Urgent Transfer: Do Not Manage the Crisis in Clinic --------------------------------------------------- Transfer every patient with suspected DKA or HHS to an emergency department. Activate EMS rather than private transport for altered mental status, seizure, hypotension, respiratory distress, severe dehydration, or inability to protect the airway. Transfer hypoglycemic patients urgently when they have: - Persistent neurologic abnormalities or recurrent low glucose - Sulfonylurea exposure or intentional overdose - Need for repeated IV dextrose - Seizure, trauma, or uncertain cause - No responsible observer or reliable glucose monitoring Begin supportive care without delaying transport. Establish IV access and provide isotonic fluid when clinically appropriate, but do not initiate office-based insulin for suspected DKA/HHS without potassium results and continuous monitoring. Hospital treatment requires coordinated fluids, insulin, electrolytes, and investigation of precipitants such as infection, MI, stroke, medication interruption, or substance exposure. [\[3\]](#cite-3 "Reference [3]") Key Takeaways ------------- - Check glucose immediately in every patient with altered mental status. - Give oral glucose only when swallowing is safe; otherwise use IV dextrose or glucagon. - Recheck glucose every 15 minutes after hypoglycemia treatment. - Look beyond glucose: check ketones, hydration, respiration, and cognition. - Suspect euglycemic DKA in symptomatic patients taking SGLT2 inhibitors. - Transfer suspected DKA, HHS, or complicated hypoglycemia urgently. Conclusion ---------- The safest Family Medicine strategy is simple: correct hypoglycemia immediately and never attempt outpatient management of a suspected hyperglycemic crisis. Glucose identifies the problem; mental status, ketones, acidosis, and dehydration determine its danger. Frequently Asked Questions ---------------------------- ### Should oral glucose be given to a confused patient with hypoglycemia? Only if the patient is alert enough to swallow safely. Otherwise, use IV dextrose or glucagon and protect the airway. ### Can DKA occur when glucose is below 200 mg/dL? Yes. Euglycemic DKA occurs particularly with SGLT2 inhibitors, pregnancy, fasting, or recent insulin use. Check β-hydroxybutyrate and acid-base status. ### Are urine ketones adequate for excluding DKA? No. Urine testing does not measure β-hydroxybutyrate, the predominant ketoacid in DKA. Blood β-hydroxybutyrate is preferred when available. ### When is glucagon preferred over IV dextrose? Use glucagon when severe hypoglycemia prevents oral intake and IV access is unavailable or delayed. IV dextrose is preferred when access is established. References (5) ------------------ 1. 1. [ American Diabetes Association. Glycemic Goals, Hypoglycemia, and Hyperglycemic Crises: Standards of Care in Diabetes—2026 ](https://diabetesjournals.org/care/article/49/Supplement_1/S132/163927/6-Glycemic-Goals-Hypoglycemia-and-Hyperglycemic) [↩](#cite-ref-1-1 "Back to text") 2. 2. [ doi.org/10.2337/dci24-0032 ](https://doi.org/10.2337/dci24-0032) [↩](#cite-ref-2-1 "Back to text") 3. 3. [ diabetesjournals.org/care/article-pdf/49/Supplement\_1/S339/848851/dc26s016.pdf ](https://diabetesjournals.org/care/article-pdf/49/Supplement_1/S339/848851/dc26s016.pdf) [↩](#cite-ref-3-1 "Back to text") 4. 4. [ Umpierrez GE, et al. Hyperglycemic Crises in Adults With Diabetes: A Consensus Report. Diabetes Care. 2024 ](https://pubmed.ncbi.nlm.nih.gov/39052901/) 5. 5. [ American Diabetes Association. 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