MICA · FIRST-LINE LEARNING NOTES
Understand, prioritise and organise follow-up
Assess abnormal glucose together with symptoms, ketones and context: the number alone does not measure metabolic severity.
Recognise a glycaemic emergency
Sweating, tremor, confusion, unusual behaviour or a neurological deficit should prompt rapid glucose measurement. Hypoglycaemia with impaired consciousness requires emergency assistance; give nothing by mouth if alertness or swallowing is impaired. Conversely, polyuria, thirst, vomiting, abdominal pain, deep breathing or drowsiness suggest a hyperglycaemic crisis. Only moderately elevated glucose does not exclude ketoacidosis, particularly during SGLT2 inhibitor treatment.
[1][2]Identify mechanism and precipitant
Identify diabetes type, medicines actually taken, recent food intake, infection, alcohol, barriers to care and known kidney function. Check glucose units and investigate measurements inconsistent with the clinical picture. In suspected ketoacidosis, blood ketones, preferably beta-hydroxybutyrate, and assessment of acidosis are central. Marked hyperglycaemia also requires evaluation of dehydration, electrolytes, kidney function and hyperosmolality in an appropriate setting.
[3][2]Hyperglycaemic crisis involves more than glucose elevation: assess acidosis, ketones, dehydration and electrolytes. SGLT2 inhibitors can be associated with ketoacidosis without marked hyperglycaemia. After hypoglycaemia, correcting glucose does not resolve its cause; long-acting medicines and renal impairment increase the risk of recurrence.
[2][1]Treat the emergency in the right setting
For an alert person who can swallow safely, hypoglycaemia requires fast-acting glucose according to an agreed plan and reassessment of the response. Impaired consciousness, persistence or recurrence requires urgent care and appropriate treatment. Suspected ketoacidosis or hyperosmolar state requires hospital assessment: fluids, insulin and potassium management must be coordinated and monitored. Do not improvise an insulin correction based on an isolated glucose reading.
[1][2]Prevent recurrence
After stabilisation, identify the cause rather than equating normalisation with definitive recovery. Severe or recurrent hypoglycaemia requires medical review of treatment, goals and education. Check understanding of warning symptoms, access to equipment and the plan for intercurrent illness. After a hyperglycaemic crisis, arrange follow-up, medicine access and ketone monitoring when indicated. The plan must reflect available resources and support.
[4][3][2]A learning situation
FICTIONAL CASE · SELF-REFLECTION WITHOUT A SCORE
A person with diabetes taking an SGLT2 inhibitor has nausea, abdominal pain and unusual breathing after reduced food intake. Glucose is not markedly elevated, so they assume diabetes cannot explain the symptoms.
Which diagnosis must not be missed?
Read the reasoning
Ketoacidosis with only modest glucose elevation remains possible. Urgent assessment should include ketones and acid–base status, investigation of the precipitant and monitored care. The pitfall is using glucose alone to exclude the diagnosis. Medication decisions belong to the team assessing and treating the episode.
References and scope
- Low blood sugar (hypoglycaemia) — symptoms, immediate actions and prevention (reviewed August2023) ↗
- Umpierrez et al. Hyperglycemic Crises in Adults With Diabetes: A Consensus Report. Diabetes Care. 2024;47:1257–1275 ↗
- Low Blood Glucose (Hypoglycemia) — causes, symptoms, treatment and prevention (reviewed July2021) ↗
- Glycemic Goals, Hypoglycemia, and Hyperglycemic Crises: Standards of Care in Diabetes—2026. Diabetes Care. 2026;49(Suppl 1):S132–S149 ↗
Original educational synthesis for adult first-line practice. International references must be interpreted with the clinical setting and local care pathways. Independent human scientific review remains to be confirmed.