A hyperglycemic crisis is a severe, life-threatening complication of diabetes characterized by dangerously high blood sugar levels. This condition involves a profound metabolic derangement that requires immediate medical intervention. Recognizing the signs and acting quickly is paramount, as delays can lead to coma, long-term complications, or death. Although both Type 1 and Type 2 diabetes can lead to this emergency, the underlying mechanisms and typical presentations differ significantly. Immediate emergency care is the only appropriate response.
The Two Forms of Hyperglycemic Crisis
Hyperglycemic crises manifest primarily in two distinct forms: Diabetic Ketoacidosis (DKA) and Hyperosmolar Hyperglycemic State (HHS). Both conditions arise from insufficient circulating insulin coupled with an increase in stress hormones like cortisol and glucagon. This hormonal imbalance prevents glucose from entering cells, causing it to accumulate dangerously in the bloodstream.
Diabetic Ketoacidosis (DKA) is far more common in individuals with Type 1 diabetes due to a near-absolute lack of insulin. Without insulin, the body breaks down fat for energy, producing acidic compounds called ketones. The rapid accumulation of these ketones leads to metabolic acidosis, the defining feature of DKA. This condition can develop rapidly, often within 24 hours, and typically involves blood glucose levels above 250 mg/dL.
Hyperosmolar Hyperglycemic State (HHS) is most often seen in older individuals with Type 2 diabetes. In HHS, the body retains enough insulin to prevent the large-scale fat breakdown that produces significant ketones, thus avoiding severe ketoacidosis. However, blood glucose levels become extremely elevated, often exceeding 600 mg/dL. This results in severe dehydration and a high concentration of solutes in the blood, known as hyperosmolarity, which causes profound neurological symptoms.
Identifying the Warning Signs
Recognizing the warning signs is the first step toward a rapid response, as the presentation varies between the two forms of crisis. Both DKA and HHS share common initial symptoms resulting from high blood sugar, such as excessive thirst, frequent urination, and unintended weight loss. These signs occur because the kidneys attempt to flush out the excess glucose, pulling large amounts of water along with it.
The distinguishing symptoms of DKA are directly related to the buildup of ketones and subsequent acidosis. A person experiencing DKA may develop a noticeable fruity odor on their breath, caused by the exhalation of acetone. Other specific signs include nausea, vomiting, abdominal pain that can be severe, and deep, labored breathing, medically termed Kussmaul breathing. These respiratory changes are the body’s attempt to expel carbon dioxide and correct the blood’s acidity.
In contrast, the unique signs of HHS are primarily neurological, tied to severe dehydration and hyperosmolarity. Symptoms often develop more slowly than DKA, sometimes over several days or weeks. These can include extreme lethargy, confusion, hallucinations, blurred vision, or focal neurological deficits like trouble moving one side of the body. The extreme fluid loss in HHS also presents as intensely dry mucous membranes and decreased skin turgor.
Essential Steps for Emergency Response
A suspected hyperglycemic crisis is a medical emergency, and the immediate action is to call emergency medical services (EMS), such as 911 or the local equivalent, without delay. Clearly state that the person has diabetes and is exhibiting signs of a severe high blood sugar emergency. Delaying professional medical treatment to attempt self-management can have fatal consequences.
While waiting for help, there are a few appropriate pre-hospital steps, provided the individual is conscious and able to cooperate. If a blood glucose meter or ketone testing strips are available, check the blood sugar and ketone levels to gather information for the emergency responders. This data helps medical personnel assess the severity of the situation immediately upon arrival. The person should be encouraged to lie down and remain calm; if they are not vomiting, they can be given small, frequent sips of water to combat dehydration.
A critical cautionary note is to avoid administering extra insulin without explicit instructions from a medical professional during the emergency call. In a severe crisis, the body’s response to insulin can be unpredictable, and inappropriate dosing can complicate the emergency team’s efforts or lead to dangerous blood sugar lows. If the person becomes unconscious, do not attempt to give them anything by mouth, including water or insulin, due to the high risk of choking. Instead, place them in the recovery position and wait for the emergency team.
Strategies for Crisis Prevention
Preventing a hyperglycemic crisis centers on consistent diabetes management, especially during periods of illness. Illnesses like the flu, a common cold, or an infection trigger the release of stress hormones, which raise blood sugar levels and counteract the effect of insulin. Having a predetermined “sick day plan” developed with a healthcare provider is an important proactive measure.
The cornerstone of crisis prevention during illness is strict adherence to “sick day rules.” This protocol requires never stopping insulin, even if the person is unable to eat or is vomiting, though the dosage may need adjustment. Monitoring must be significantly increased, with blood glucose and ketone levels checked every three to four hours, including through the night, to catch dangerous trends early. Maintaining hydration is also paramount, requiring the consumption of 120 to 180 milliliters of fluid every half hour to prevent severe dehydration.
Beyond sick day management, crisis prevention relies on consistent medication adherence. Taking insulin and all other prescribed glucose-lowering medications exactly as directed is necessary for maintaining stable metabolic control. Regular monitoring of blood glucose and a periodic check of the A1C level provides a long-term picture of diabetes control, signaling when adjustments to the management plan may be needed. Individuals taking certain medications, such as SGLT2 inhibitors, may need to temporarily stop them during illness, so discussing specific drug protocols with a doctor beforehand is necessary.