Diabetic Emergencies: Hypoglycemia vs. DKA vs. HHS
How EMS providers tell hypoglycemia, diabetic ketoacidosis, and hyperosmolar hyperglycemic state apart in the field, and what to do about each.
August 28, 2026 · 7 min read
Every diabetic emergency starts with a glucose check. From there, three patterns dominate: hypoglycemia (fast onset, sweaty, altered), DKA (gradual, Kussmaul respirations, fruity breath), and HHS (slow, profoundly dehydrated, no ketones).
Hypoglycemia
BGL < 70 mg/dL with symptoms. Oral glucose if the patient can protect their airway; IV/IO D10 or D50, or IM glucagon if no IV access. Recheck in 10 minutes.
DKA
Type 1 diabetics, BGL often 300–800, Kussmaul (deep, rapid) respirations blowing off CO₂ to compensate for acidosis, dehydrated, fruity breath. Treatment is fluid, transport, and insulin at the hospital — not in the field for most systems.
HHS
Type 2 diabetics, BGL often > 600 mg/dL, profoundly dehydrated, altered but usually no significant ketones. Fluid resuscitation and rapid transport.
The exam trap
Any altered patient with a stroke-like presentation gets a glucose check before you activate stroke alert. Hypoglycemia mimics almost every neurologic emergency.
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