This document provides guidance on navigating diabetes emergencies by correcting high blood glucose, identifying the cause, learning from the experience, and considering factors like fluids, insulin adjustments, nutrition, and activity level. It also includes examples of blood glucose and ketone levels over time and guidance on when to call the diabetes care team, as well as details on using mini-dose glucagon for hypoglycemia during illness.

1. How to navigate through a diabetes emergency April 26, 2014
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How to navigate through a diabetes emergency:
Correct the Blood glucose
Chase down the Cause
Consider what you learned
High BG, ketones and sick days
2 key concepts: fluids and insulin
What ketones tell you
Fluid management
Insulin adjustments

2. How to navigate through a diabetes emergency April 26, 2014
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Other considerations: nutrition, activity, frequency of monitoring, preventing
hypo (mini glucagon rescue)
Practice examples
Time Blood
glucose
Ketones What to do ?
7 AM 450 Large
9 AM 380 Large
12 N 350 Moderate
2 PM 260 Moderate
4 PM 346 Small
6 PM 230 Moderate
9 PM 180 Moderate
When would you call the diabetes team?
Yes No,
not yet
Situation
Gave 3 extra doses and child no better (still sleepy and won’t drink)
Gave 2 extra doses, child drinking and eating well, ketones coming down
Fever, won’t drink
Breathing hard, looks sick
Sore throat, blood glucose high but no ketones
BG high, no ketones, gave usual AM dose, now child won't eat
Child vomited twice, BG normal, small ketones, due for supper dose

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Mini Dose Glucagon Rescue for hypoglycemia during illness
Consult your diabetes team about the use of this treatment!
When to use:
• BG less than 80 AND
• Stomach illness with nausea or vomiting
DO NOT USE Mini dose glucagon AS A TREATMENT FOR SEVERE
HYPOGLYCEMIA. Use the full dose of glucagon.
Mini dose glucagon Dosing:
Age Initial Dose (glucagon drawn with
an insulin syringe)
2 years and younger 2 units (20 mcg)
2 to 15 years old 1 unit (10 mcg) for year of age
15 and older 15 units (150 mcg)
What to expect:
• BG may rise 60-90 mg/dl and last about one hour.
• If the BG does not rise sufficiently within 20-30 minutes the glucagon
dose can be doubled and given again.
• These doses may be given every 1-2 hours as needed.
• Mixed glucagon can be stored in the refrigerator and used for up to
24 hours. Any unused glucagon should be discarded after 24 hours.
Reference
Haymond, M. ,& Schreiner, B. (2001). Mini-dose glucagon rescue for hypoglycemia in children with Type
1 diabetes. Diabetes Care. 24(4): 643-645.

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Finding patterns in the chaos:
Putting blood sugar data to work to predict and prevent problems
What
• What are your BG goals?
When
• When are BG levels out of target?
Why
• Why are the BG levels out of target?
How
• How will you bring the BG levels back into target?
References
Chase, Peter. (2006). Understanding Diabetes, 11th Edition
Chase, Peter. (2007). Understanding Insulin Pumps & Continuous Glucose Monitors
Available to read at:
http://www.ucdenver.edu/academics/colleges/medicalschool/centers/BarbaraDavis/Onli
neBooks/Pages/default.aspx

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Brk Lu Su Brk
AA BB CC DD EE FF
Brk Lu Su Brk
AA BB CC DD EE FF
Brk Lu Su Brk
AA BB CC DD EE FF
WHEN?
INTERPRETING BLOOD GLUCOSE VALUES
Time
Frame
Blood glucose Dose affected
1-2 hours after Breakfast Breakfast Bolus
4-5 hours after Breakfast Basal
1-2 hours after Lunch Lunch Bolus
4-5 hours after Lunch Basal or
May indicate need for snack bolus
1-2 hours after Supper Supper Bolus
Overnight:
9-12 MN
MN-3 AM
3AM-7 AM
Basal rate: 30 mg/dl difference from one time
frame to another may indicate need to adjust
rate
(Some need an overnight rate twice the daytime
rate)

6. How to navigate through a diabetes emergency April 26, 2014
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WHY?
INSULIN •Amount: What are current doses?
•Timing: When is the insulin given in relation to the meal?
•Freshness: How old is the vial or pen of insulin being used?
•How is insulin stored?
•Is it the correct type of insulin?
•Is the total daily amount reasonable?
•How does the insulin seem to work for this child?
• Who gives the dose — if child, is he or she supervised?
• Is it possible that doses have been missed? How often?
• Have doses recently changed? What was the effect?
SITES •Are sites lumpy?
•What is current rotation pattern?
•What angle is used for injection?
•What length needle is used? Is injection going too shallow?
•Does insulin leak from site after injection?
CHILD
GROWTH
• How old is child? Going through growth spurt?
• (Girls) Is menarche/menses affecting BG?
• (Girls) Is it possible the teen is pregnant? (Episodes of unexplained
hypoglycemia may occur in 1st trimester.)
HYPO-
GLYCEMIA
•What time of day? What are common symptoms?
•What is BG during symptoms? What is BG following episode?
•How is hypoglycemia treated? Is it overtreated?
•Nausea
•Nightmares; restless sleep
•Chronic headache; headache in morning when wakes up
KETONES •Are ketones only in am. — and clear later in day without extra insulin?
•Are there ketones at other times?
•How quickly do the ketones clear and by what means?
EXERCISE • What type/duration/time? If child, when is PE?
• Is child experiencing post exercise hypoglycemia?
DIET •Adherence with meal plan? What types of snacks?
•How close is meal time to testing time?
LIFE
ISSUES
•Is there family/work/school stress?
•Could there be an eating disorder?
•Has there been unexplained weight gain or loss?
CHECKING • What type of meter is used? Any recent meter problems?
• When was it last calibrated or controlled?
• If child, is he or she supervised?
• What are BG results at "odd" times (after meals, night, etc.)
• What is the recent A1c result?