Diabetes mellitus (main)

Background

• Growing in worldwide prevalence
• Results from either inability of the body to release insulin from the pancreas or a resistance against the actions of insulin

Clinical Features

• Patients with diabetes may be asymptomatic
• Acute symptoms may range from those of nonketotic hyperglycemia (e.g. polyuria, polydipsia) to DKA (ill appearance, acetone breath, Kussmaul's breathing, somnolence)

Differential Diagnosis

Hyperglycemia

• Physiologic stress response (rarely causes glucose >200 mg/dL)
• Diabetes mellitus (main)
  • Nonketotic hyperglycemia
  • Hyperosmolar hyperglycemic state (HHS/HONC)
  • Diabetic ketoacidosis (adult)
  • Diabetic ketoacidosis (peds)
    • Cerebral edema in DKA
  • Diabetic foot infection
  • Diabetic peripheral neuropathy
• Hemochromatosis
• Iron toxicity
• Sepsis

Evaluation

• Diabetes mellitus itself is not normally a diagnosis sought in the emergency department (i.e. via A1C)
• Hyperglycemia can be found on laboratory testing
  • Asymptomatic patients do not necessarily require additional testing
  • Symptomatic or potentially symptomatic patients require additional testing
    • Check CBC, BMP, and ketones (if sick see additionally DKA workup)
    • UA is only necessary if you are ruling out urinary infection or do not have serum ketones available and are using it as a screening mechanism

Management

• May consider IV hydration or IV insulin administered in the ED
• All patients with diabetes newly diagnosed in the ED will require reliable follow-up for education and blood sugar monitoring
• May consider discharging patient with prescription for metformin, starting dose is 850 mg daily

See Also

• Hypoglycemia
• Evidence Review Sodium Bicarbonate in DKA
• EBQ:Relevance of Discharge Glucose Levels