Metabolic and Endocrine Emergencies

Diabetic ketoacidosis, hyperkalemia and hypoglycemia.

Metabolic and Endocrine Emergencies

Diabetic Ketoacidosis

• A complication of diabetes mellitus where there is little to no insulin available to carry glucose into cells, leading to hyperglycemia. As the body is unable to use glucose for energy, it begins to break down fats, creating ketones as a by-product. Ketones are acidic and as they build up from fat breakdown, metabolic acidosis results. Hyperglycemia leads to osmotic diuresis, causing dehydration. The dehydration and metabolic acidosis lead to electrolyte abnormalities, and as the metabolic acidosis worsens organ dysfunction begins, ultimately, if left untreated, death. o The key issues are dehydration and electrolyte abnormalities from hyperglycemia and osmotic diuresis. As well as metabolic acidosis from ketones as a result of fat breakdown. o As a result patients will present with nausea, vomiting and abdominal pain as acid levels within the GI Tract are affected. Weakness and fatigue from impaired glucose use. Rapid breathing(Kussmaul) to help mediate acidosis by blowing off CO2. ALOC from a combination of the acidosis, dehydration, impaired glucose usage and electrolyte abnormalities. The classic symptoms are increased urination and increased thirst. ▪ Ultimately, when severe, signs of shock such as hypotension and tachycardia will be present. o Causes include first onset diabetes mellitus, insulin noncompliance, infections, stress, trauma, alcohol binging and pancreas issues. • Specifics of the workup o Point of Care Glucose: To assess the level of glucose present. May read as 'high' o Beta-Hydroxybutyrate (BHU): A ketone produced during fat breakdown. The higher the level, the worse off ketoacidosis is, prompting more aggressive management. o CBC: Helps assess for infections. Infections can lead to a patient going into DKA. o BMP: Helps assess electrolyte abnormalities and abnormalities with organs (Renal Function, Liver Labs, Pancreas and so forth) ▪ Provides lab values necessary to calculate Anion Gap ( Sodium - Chloride - Bicarb ). ▪ The anion gap is used to gauge the severity of acidosis. The body likes to stay in homeostasis, balancing cations(positive) and anions(negative), with a normal gap value being less than 12. When there are outside substances like acidic ketones, the body becomes more acidic, raising the anion gap to levels greater than 12. As a result, we can calculate the anion gap to gauge how acidotic the body is. o Urinalysis: Helps assess for ketones in the urine and possible sources of infection o Lactate: Assess for hypoperfusion as lactate is a byproduct of anaerobic metabolism, an indicator of poor perfusion to cells/organs o Infectious Workup if suspected: Chest Xray (pna etc), Blood Cultures, Urine Cultures, CT's (Remember the most common areas of severe infections are the chest, abdomen and pelvis) • Treatment o Fluid Administration: Normal Saline or Lactated Ringers ▪ 30ml/kg or 1-2 L over 1 hour ▪ Fluid administration helps treat the dehydration associated with osmotic diuresis and constant vomiting. o Intravenous Insulin Therapy/Infusion: Key Treatment of DKA ▪ *Only Regular Insulin can go IV* ▪ Insulin will help cells use glucose for energy, stopping the breakdown of fats and production of ketones. This also reverses hyperglycemia, stopping osmotic diuresis. ▪ Ensure potassium level is not low, if it is, it needs to be actively replaced while the insulin infusion is ongoing. Insulin drives potassium into cells, and if the levels are already low, it will cause further hypokalemia, which we know hypokalemia can be very irritating to the heart. ▪ Check POC Glucose Hourly to monitor trend, ideally should be dropping 50-70 per hour. Also to ensure the patient does not go hypoglycemic while on the insulin infusion. ▪ Repeat BMP Q 4 hours to monitor electrolytes closely, as well as to calculate anion gap. (Sodium - Chloride - Bicarb) o Replace Electrolytes as needed ▪ Potassium Level must be greater than 3.3 prior to starting insulin infusion • 10mEq peripherally per hour • 20mEq via central line per hour • PO: 40 mEq (PO pills are large, hard to swallow and can irritate the stomach, causing nausea) ▪ Replace magnesium as it helps maintain potassium levels o Treat underlying cause if present ▪ A big one here is infections. Locate source, culture if possible and administer antibiotics. • Transitioning to SubQ Insulin / Resolved Ketoacidosis o Several criteria need to be met for the patient to be able to come off the insulin infusion ▪ Anion gap less than 12 ▪ Bicarb >18 ▪ Pt is able to tolerate PO food intake o Once criteria are met, a long acting insulin is administered. The infusion remains ongoing for 2 hours after it was administered, then it can be discontinued. The long acting is administered concurrently to prevent hyperglycemia since it could easily throw the patient back into DKA. • Nursing o Ask questions regarding possible precipitating sources like infections. Symptoms such as fever, chills, cough, sore throat, wounds and dysuria. Infections promote stress in the body, can cause electrolyte issues and the body naturally increases levels of glucose. For diabetics this is a perfect recipe for dka. o GAP calculation: Sodium - Chloride - Bicarb o Recheck glucose after fluid resuscitation (Prior to starting infusion) o Insulin Infusion ▪ Only Regular Insulin can go IV ▪ Wait for potassium level prior to start IV Insulin(Shifts potassium into cells, may need to replace it at the same time to prevent any cardiac effects) ▪ Check glucose hourly ▪ Repeat BMP q 4 hours to monitor electrolytes and calculate gap o Have at least 2 IV'S. One will be for the insulin infusion, while the others can be used for fluids and possible electrolyte replacements. o For nausea, Reglan works better than Zofran in diabetic patients as it promotes gastric emptying and gastric mobility, which are often problems dka patients have o IV Potassium is irritating to veins. Try to use a larger vein, or slow down rate or dilute with another normal saline infusion at a slow rate (per provider order) ▪ Remember potassium IV is only 10 mEq per hour if peripheral, 20 mEq if central line.

Hyperkalemia

• Hyperkalemia is elevated potassium in the blood, with levels above 6mEq/L being concerning as high potassium can disrupt the electrical activity of the heart, leading to deadly arrhythmias. o Causes include kidney failure, missing dialysis, burns, rhabdomyolysis and certain medications such as potassium sparing diuretics. However, you'll most commonly deal with hyperkalemia with renal issues. Another cause can be cell breakdown from an inadequate blood draw (prolonged tourniquet use, slow flow, using a syringe). o Symptoms can include arrhythmias, ECG changes (Peaked T waves, Widening QRS), muscle weakness, fatigue, nausea and vomiting. Hyperkalemia is also commonly found on routine lab work, pt are told to go to the ER. • Specifics of the workup: These patients often have other complaints that require additional and more in depth workups. For Hyperkalemia, the workup goes as follows: o Complete Metabolic Panel: Assess electrolytes including potassium. Assess kidney function as the kidneys are in charge of maintaining electrolyte balances, especially potassium. o ECG: Assess for any ECG changes indicative of hyperkalemia such as peaked T waves and a widening QRS. Also to assess whether any arrhythmias are present as that indicates the heart may already be irritated from the high levels of potassium o CBC: To ensure nothing is missed like an elevated white count or a low hemoglobin o Urinalysis: To assess renal function and any abnormalities • Treatment o Calcium Gluconate ▪ Stabilizes the cardiac membrane, reducing heart irritability from potassium, helping prevent arrhythmias ▪ 1 gram over 10 minutes ▪ If hyperkalemia is causing instability and arrhythmias, I've seen up to 3 grams given initially. o Insulin and Glucose ▪ Insulin drives potassium into the cell, reducing extracellular potassium ▪ Since insulin will also lower glucose levels, an amp of Dextrose is also given ▪ 10 Units of Regular Insulin are typically given IV. If the glucose is already low prior to insulin administration, notify the providers and they may change to 5 Units, especially in renal patients, as the kidneys are incharge of clearing insulin. o Sodium Bicarb ▪ Shifts potassium into cells. Acidosis causes cells to release potassium while alkalosis causes cells to take in potassium. Bicarb is given to help create alkalosis, causing potassium to shift into cells ▪ 50mEq (an amp) is typically given IV o Kayexalate ▪ Binds potassium in the GI tract which is ultimately excreted. This helps maintain potassium levels within adequate levels ▪ Kayexalate is important to give, however, it does take 4-6 hours to begin working so prioritize the above medications first. o Other medications can include ▪ Albuterol • Shifts potassium inside cells. Consult with provider if the patient is tachycardic as albuterol will further increase the HR ▪ Lasix • Helps increase potassium excretion by kidneys • Ensure the patient produces urine prior to administration, if they do not produce urine there is no point in administration. This is mainly for dialysis patients. ▪ IV fluids • To dilute blood and as a result lower concentration of potassium o Dialysis ▪ Key treatment for severe hyperkalemia. Dialysis will remove excess potassium. ▪ Providers will need to place an emergency large bore catheter and dialysis department/RN would need to be readily available • Nursing o Calcium Gluconate (Not Chloride-only for codes) ▪ Give the calcium gluconate first so it begins to stabilize the heart. As it is infusing, you can work on gathering other medications. o Kayexalate is important, however, prioritize other meds first since it can take up to 6 hours to start working o Only Regular Insulin can go IV o Recheck poc glucose within 30 minutes to ensure glucose levels are maintaining since you most likely gave insulin o A VBG can yield a potassium result rapidly compared to waiting for the bmp. Although you will still get a BMP, getting a VBG for the potassium can be useful Keep these patients on a cardiac monitor

Hypoglycemia

• A low blood glucose level. Technically less than 70, however, symptoms typically start once levels start dropping below 60. The body as a whole will suffer from low glucose levels, however, the brain and heart are most notable. If hypoglycemia is severe and prolonged, permanent brain damage will occur. The heart will also suffer from hypoglycemia as the body will be in a stress response, prompting the heart to beat faster and faster while having little glucose for energy. This demand will eventually lead to arrhythmias and eventual cardiac arrest. o Patients can present with shakiness/tremors, pale and sweaty, tachycardic, confused/altered. As it progresses, worsening confusion, loss of consciousness, seizures and eventually heart issues and death if left untreated. o Causes are most commonly from insulin issues and diabetic medications, whether taking too much insulin or their regular Sulfonylureas or even not eating when they are supposed to. ▪ Other very important causes you need to be aware of include hypoglycemia as a result of sepsis, liver failure and hypothermia. I want to highlight sepsis specifically. Check a point of care glucose with critical septic patients regularly. There's been plenty of times when these patients were relatively stable and suddenly started decompensating and no one could figure out why until a more seasoned nurse said "Has anyone checked the sugar?" • Specifics of the workup o Poc Glucose Testing: To assess glucose level o Health and History Assessment/Questioning: Crucial in identifying use of insulins and diabetic medications, their last use, dose and if patient ate. You should also be inquiring about any potential illness(infectious sources) and whether the patient has been binge drinking alcohol (when this happens patients tend not to eat). o The basic workup will also be done to help assess overall patient status including a CBC and BMP. ▪ If suspected, cortisol levels for adrenal issues. Liver Function as the liver also plays a role in glucose levels and other very specific tests (not common). o These patients, as they are often confused/altered, will also get the altered workup to ensure nothing is missed. Mainly a head CT to ensure no intracerebral issues. • Treatment o If the patient is awake, alert, protecting their airway and able to swallow, eating is the first line. Typically, in the ER, we'll have them drink juice (some nurses add an extra sugar packet) then provide them with a meal. o Amp of D50 ▪ 25g of Dextrose in a 50 ml 50% Solution of Dextrose ▪ Used as IVP when glucose levels are very low, the patient is symptomatic and unable to safely eat. o Glucagon ▪ If IV access is not available and or staff is having a difficult time obtaining IV access, Intramuscular Glucagon can be given to help bring glucose levels up. It acts on the liver to help release glucose stores. ▪ Again, for hypoglycemia, only administered IM when there is no IV access for an Amp of D50 (I have only done this once or twice in my whole career so not very common) ▪ A very common side effect of glucagon is nausea and vomiting. Keep this in mind and be prepared to deal with the vomiting and any airway issues it may cause. (Turn them so they do not aspirate) • (Glucagon is also given for beta blocker OD. It will also cause nausea and vomiting. Give an antiemetic with it) o D5 ▪ Once the glucose level has been stabilized but continues to trend down. The patient may be started on a D5 drip/infusion to help maintain their glucose levels. o D10 ▪ If the D5 is not enough because the glucose is rapidly lowering, a D10 drip should be started to help maintain glucose levels. • Nursing o Repeat Glucose check after interventions to ensure glucose is trending up. o If Glucose keeps trending down, let the team know so they can order additional D50 Amps and start them on an infusion of D5/D10 o Check a POC Glucose in your critical patients when they are decompensating and you can't figure out why. o When pushing an AMP of D50, if a small vein is used, push slowly, so you do not blow it as it will be a lot of pressure. Ideally a larger upper forearm and AC vein.

Updated 2 Sep 2026