Hyperglycemic Crisis

Ronald Van Ness-Otunnu, MD, MS; Jason B. Hack, MD, FACEP


J Emerg Med. 2013;45(5):797-805. 

In This Article

Abstract and Introduction


Background: Hyperglycemic crisis is a metabolic emergency associated with uncontrolled diabetes mellitus that may result in significant morbidity or death. Acute interventions are required to manage hypovolemia, acidemia, hyperglycemia, electrolyte abnormalities, and precipitating causes. Despite advances in the prevention and management of diabetes, its prevalence and associated health care costs continue to increase worldwide. Hyperglycemic crisis typically requires critical care management and hospitalization and contributes to global health expenditures.

Objective: Diagnostic and resolution criteria and management strategies for diabetic ketoacidosis and hyperosmolar hyperglycemic crisis are provided. A discussion of prevalence, mortality, pathophysiology, risk factors, clinical presentation, differential diagnosis, evaluation, and management considerations for hyperglycemic crisis are included.

Discussion: Emergency physicians confront the most severe sequelae of uncontrolled diabetes and provide crucial, life-saving management. With ongoing efforts from diabetes societies to incorporate the latest clinical research to refine treatment guidelines, management and outcomes of hyperglycemic crisis in the emergency department continue to improve.

Conclusion: We provide an overview of the evaluation and treatment of hyperglycemic crisis and offer a concise, targeted management algorithm to aid the practicing emergency physician.


Hyperglycemic crisis includes diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS). Both are extreme metabolic derangements associated with uncontrolled types 1 and 2 diabetes mellitus that may result in shock, coma, or death. These life-threatening endocrine emergencies demand swift, repeated clinical and laboratory assessment; monitoring; correction of hypovolemia, acidemia, hyperglycemia, ketonemia, and electrolytes; and treatment of the precipitating causes. Consensus statements provided by the American Diabetes Association (ADA) for the care of adult patients with hyperglycemic crisis and by the International Society for Pediatric and Adolescent Diabetes (ISPAD) for the care of children and adolescents with DKA are excellent primary resources for diagnosis and management.[1,2]

As of 2010, >285 million adults worldwide have diabetes, with estimated yearly global health expenditures totaling >$376 billion.[3] In the United States (US), the number of Americans with diabetes has more than quadrupled, from 5.6 million in 1980 to 25.8 million in 2010, with direct and indirect health care costs of >$174 billion.[3,4] The incidence of type 1 diabetes is increasing globally, particularly in children <5 years of age, and the earlier onset of type 2 diabetes is a growing concern.[5] In a multicenter, population-based study of patients <20 years of age who were diagnosed with diabetes, the prevalence of DKA at the initial diagnosis was >25%.[6] US population–based studies report the annual incidence of DKA to range from four to eight episodes per 1000 diabetic patient admissions, with an average duration of hospital stay of 3.6 days.[4,7] Hyperglycemic crises often require critical care management and are associated with significant health care costs, morbidity, and mortality. The mortality rate from DKA in children ranges from 0.15% to 0.30%, with cerebral edema responsible for 60% to 90% of these deaths.[2] Among adults, DKA-associated mortality is often attributable to precipitating or concurrent events, such as sepsis, pneumonia, hypokalemia, acute myocardial infarction (MI), and acute respiratory distress syndrome.[8]

Improved understanding of pathophysiology and advances in diabetes prevention and management has resulted in sharply declining death rates in the United States.[9] In 1980, among the 0- to 44-year-old age group, 45.5 deaths per 100,000 diabetic patients were attributable to hyperglycemic crisis, compared with 26.2 in 2005.[4] In patients >75 years of age, even greater improvement was observed, with 20.5 deaths per 100,000 in 2005 compared with 140.2 per 100,000 in 1980.[4] Ongoing research holds promise for further decreases, including the early identification and management of patients at risk, improvements in the accuracy and efficiency of acidosis measurement, and trials of alternative insulin regimens for acute management.[10]