Glycemia = glucose level in blood. 

Normal levels 3,9 - 5,6 mmol/l.  

Hypoglycemia 

Definition: glycemia below 3,9 mmol/l.

Symptoms: depends on hypoglycemia severity. 

• A: if the patient is unconscious, the airway could be obstructed (inspiratory stridor, grunting)
• B: pale; if the airway is patent, the breathing is mostly not seriously affected. 
• C: tachycardia, hypotension, sweating. 
• D: agitation, confusion, tremor, fatigue, hunger, somnolence, sopor, coma, glycemia below 3,9 mmol/l. 
• E: look for diabetes mellitus in patient history and last insulin administration.

Therapy: 

• 1.) If the patient is responsive, make him drink or eat fast-acting carbohydrates.  
• 2.) If the patient is unresponsive and has a glucagon injection (spray) on him, use it according to the manual. Do not forget that glucagon is short-acting, and the patient needs glucose supplementation.  
• 3.) Cannulate the vein or secure IO access and administer glucose (f.e. 20 ml of 40% glucose).
• 4.) Look for the causes - adjust the insulin dosing...

Hyperglycemia 

Diabetic ketoacidosis (DKA)

Definition: complication or first manifestation of diabetes mellitus, mostly type I. This state is a characteristic triad of hyperglycemia, metabolic acidosis, and ketonemia. 

Symptoms: 

• A: fruity-scented breath; if the patient is unconscious, the airways could be obstructed.
• B: tachypnoea, Kussmaul breathing.
• C: tachycardia, hypotension, polyuria; lab tests: hyperglycemia, ketonemia, normal osmolality, severe metabolic acidosis in ABG; Lab urine: high concentration of ketones and glucose. 
• D: nausea, vomiting, fatigue, somnolence, sopor, coma. 
• E: patients history: diabetes mellitus type I or thirst, often urination, weight loss, fatigue.

Therapy: 

• 1.) Symptomatic therapy according to vital function alteration in ABCDE. 
• 2.) IV fluids - bolus 1000 ml balanced crystalloids within 1 hour.
• 3.) Potassium substitution. 
• 4.) ICU admission. Insulin should be administered when the potassium levels are above 3 mmol/l. Experienced physicians should manage insulin administration. Too rapid correction of hyperglycemia can lead to a sudden drop in serum osmolality, and it could lead to cerebral oedema.

Hyperosmolar hyperglycemic state (HHS)

Definition: a complication of diabetes mellitus, mostly type II. This state is characteristic of severe hyperglycemia, hyperosmolality, and dehydration. 

Symptoms: 

• A:  if the patient is unconscious, the airways could be obstructed.
• B: hypoventilation.
• C:  tachycardia, hypotension, Labs blood: hyperglycemia (more severe than in DKA), high osmolality, mild or no metabolic acidosis in ABG, Labs urine: high glucose concentration.  
• D:  somnolence, sopor, coma.
• E: patient´s history: diabetes mellitus type II.

Therapy: 

• 1.) Symptomatic therapy according to vital function alteration in ABCDE. 
• 2.) IV fluids - bolus 1000 ml balanced crystalloids within 1 hour 
• 3.) Potassium substitution. 
• 4.) ICU admission. Insulin should be administered when the potassium levels are above 3 mmol/l. Experienced physicians should manage insulin administration. Too rapid correction of hyperglycemia can lead to a sudden drop in serum osmolality, and it could lead to cerebral oedema.