Both are high-glucose emergencies. DKA = ketones and acid. HHS = extreme glucose and dehydration.
DKA vs. HHS, Plus Insulin Timing
Both are high-glucose emergencies. DKA = ketones and acid. HHS = extreme glucose and dehydration.
DKA: diabetic ketoacidosis
- Usually type 1; can happen in type 2
- Develops in hours to a day
- Glucose 200 mg/dL or higher (or known diabetes)
- Ketones: beta-hydroxybutyrate 3.0 mmol/L or higher
- pH below 7.3 and/or bicarbonate below 18
- Kussmaul breathing, fruity breath, belly pain, vomiting
HHS: hyperosmolar hyperglycemic state
- Usually older adults with type 2
- Develops over days to weeks
- Glucose 600 mg/dL or higher
- Little or no ketones
- pH 7.3 or higher, bicarbonate 15 or higher
- Severe dehydration, confusion, seizures; osmolality above 300
Treatment order (both)
- Fluids firstIV isotonic fluids to restore volume
- Check potassiumBelow 3.5? Replace it and hold insulin until it's back up
- IV insulinRegular insulin by continuous infusion
- Add dextroseWhen glucose falls below 250, so insulin can keep clearing ketones
- Watch closelyGlucose hourly, potassium, neuro status, intake and output
Insulin timing (subcutaneous)
| Type | Onset | Peak | Lasts |
|---|---|---|---|
| Rapid: lispro, aspart | 5–15 min | 45–75 min | 3–5 hr |
| Short: regular | 30–60 min | 2–4 hr | 6–8 hr |
| Intermediate: NPH | about 2 hr | 4–12 hr | 18–26 hr |
| Long: glargine | 3–4 hr | No peak | 24 hr |
Give rapid-acting insulin with the meal. Peak time is when low blood sugar is most likely.
Low blood sugar: below 70
- Shaky, sweaty, fast heart rate, confused, irritable
- Rule of 15: 15 g of fast sugar (4 oz juice), recheck in 15 minutes, repeat if still low
- Then a snack or meal
- Can't swallow safely or unconscious: glucagon or IV dextrose, nothing by mouth
Sources
- Umpierrez GE, et al. Hyperglycemic Crises in Adults With Diabetes: A Consensus Report. Diabetes Care. 2024;47(8):1257–1275.
- Merck Manual Professional Version. Onset, Peak, and Duration of Action of Human Insulin Preparations.
- American Diabetes Association. Standards of Care in Diabetes: Glycemic Goals and Hypoglycemia.
For exam study only. In clinical practice, follow your facility's policies, the prescriber's orders, and current references. Free to print and share for personal and classroom study; not for resale. NCLEX® is a registered trademark of NCSBN, which does not endorse NCLEXSim.
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