Hyperglycaemia with dehydration

Any person, 16 years and over, presenting with high blood glucose level (BGL over 15 mmol/L) with at least one of the clinical features identified in signs and symptoms or red flags.

History prompts, signs and symptoms

These are not exhaustive lists. Maintain an open mind and be aware of cognitive bias.

Red flags

Recognise: identify indicators of actual or potential clinical severity and risk of deterioration.

Respond: carefully consider alternative ECAT protocol. Escalate as per clinical reasoning and local CERS protocol, and continue treatment.

Clinical assessment and specified intervention (A to G)

If the patient has any Yellow or Red Zone observations or additional criteria (as per the relevant NSW Standard Emergency Observation Chart), refer and escalate as per local CERS protocol and continue treatment.

Position

Assessment	Intervention
General appearance/first impressions	Position of comfort

Airway

Assessment	Intervention
Patency of airway	Maintain airway patency Consider airway opening manoeuvres and positioning

Breathing

Assessment	Intervention
Respiratory rate and effort Auscultate chest (breath sounds) Oxygen saturations (SpO2)	Assist ventilation, as clinically indicated Consider oxygen if dyspnoeic, titrate oxygen to maintain SpO2 over 93% Patients at risk of hypercapnia, maintain SpO2 at 88–92% Note: Kussmaul respirations (deep sigh) is a sign of severe illness in diabetic ketoacidosis (DKA)

Circulation

Assessment	Intervention
Perfusion (capillary refill, skin warmth and colour) Pulse Blood pressure Cardiac rhythm	Assess circulation and dehydration status Attach cardiac monitor and complete 12 lead ECG if BP/HR are within the Yellow or Red Zones, or where clinically relevant, e.g. irregular pulse, palpitations, syncope, shock, respiratory compromise, cardiac history or clinical concern
IVC and/or pathology	Insert IV cannula, if trained If unable to obtain IV access, consider intraosseous, if trained See pathology section
Signs of dehydration: Sunken eyes Dry mucous membranes Concentrated urine	Give 1000 mL sodium chloride 0.9% IV over 60 minutes, once only. Use caution for patients with known heart failure or known dialysis
OR
Signs of shock: tachycardia and CRT 3 seconds and over and/or abnormal skin perfusion and/or hypotension	If signs of shock present and/or SBP less than 90 mmHg, give 250 mL of sodium chloride 0.9% IV/intraosseous bolus Repeat every 10 minutes (up to 1000 mL) until SBP over 90 mmHg or signs of shock have resolved If not responsive, consider other causes for hypotension, e.g. sepsis or primary cardiac event

Disability

Assessment	Intervention
GCS, pupillary response and limb strength	Obtain baseline and repeat assessment, as clinically indicated
Pain	Assess pain. If indicated, give early analgesia as per analgesia section then resume A to G assessment

Exposure

Assessment	Intervention
Temperature	Measure temperature
Skin inspection, including posterior surfaces	Check and document any abnormalities

Fluids

Assessment	Intervention
Hydration status: last ate, drank, bowels opened, passed urine or vomited	Closely monitor fluid input and output Maintain a strict fluid balance
Nausea and/or vomiting	If present, see nausea and/or vomiting section

Glucose

Assessment	Intervention
BGL	Measure BGL Measure ketones: If ketones over 3.0 mmol/L, escalate immediately as per local CERS protocol, consider DKA Check if patient has an insulin pump in situ: Check for kinks and integrity of the line If patient is able, re-site cannula

Focused assessment

Complete a dehydration focused assessment.

Precautions and notes

• Early management priorities are to treat shock and dehydration, followed by administration of insulin.
• Underlying causes may include:
  • infection
  • newly diagnosed type 1 diabetes
  • insufficient insulin, e.g. missed medication or pump failure
  • infarction (myocardial, cerebral, gastrointestinal or peripheral vascular)
  • concurrent illness, e.g. sepsis, diarrhoea or vomiting.
• Electrolytes and blood gases provide important information for patient management, especially in DKA and HHS. They should be checked until the resolution of either DKA or HHS.
• Consider insulin therapy once a serum potassium is known, i.e. over 3.3 mmol/L.
• Cerebral oedema can occur suddenly and is more common in people under 20 years. Mortality is high. Signs include:
  • headache, lethargy and irritability, followed by altered consciousness
  • bradycardia, hypertension and respiratory impairment.

Interventions and diagnostics

Specific treatment

• GCS must be completed hourly, or more frequently when clinically indicated.

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Analgesia

If pain score 1–6 (mild–moderate), give:

• paracetamol 1000 mg orally once only
• and/or ibuprofen 400 mg orally once only.

If severe pain present, give analgesia and escalate as per local CERS protocol.

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Nausea and/or vomiting

If nausea and/or vomiting is present, give:

• metoclopramide 10 mg orally or IV/IM once only (over 20 years only)
• or ondansetron 4 mg orally or IV/IM. If symptoms persist after 60 minutes, repeat once, maximum dose 8 mg
• or prochlorperazine 5 mg orally once only or 12.5 mg IV/IM once only

Choice of antiemetic should be determined by cause of symptoms.

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Thiamine

If patient is experiencing alcohol withdrawal, or is at high risk of thiamine deficiency (e.g. those who drink large amounts of alcohol or who are severely malnourished), then:

• monitor using alcohol withdrawal scale
• give thiamine 300 mg IV/IM once only

If hypoglycaemic: thiamine should be given before glucose, or as soon as possible. Glucose can further deplete thiamine stores and precipitate Wernicke encephalopathy.

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Radiology

• If underlying respiratory or cardiology pathology suspected: CXR

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Pathology

• FBC, UEC, LFT, VBG, Ca/Mg/PO4, glucose
• Serum ketones
• Urinalysis: mid-stream (preferred), clean catch or catheter urine. If positive for nitrites and/or leucocytes send for MC&S. Keep sample refrigerated if transport delayed
• Temp less than 35°C or over 38.5°C: take two sets of blood cultures from two separate sites
• Female of childbearing age: urine βHCG. If positive and within the first trimester, send serum βHCG for quantitative analysis

Medications

The shaded sections in this protocol are only to be used by registered nurses who have completed the required education.

Medications with contraindications or requiring dose adjustment are marked:

• ^H for patients with known hepatic impairment
• ^R for patients with known renal impairment.

Escalate to medical or nurse practitioner.

Evidence informed	Information was drawn from evidence-based guidelines and a review of latest available research. For more information, see the development process.
Collaboration	This protocol was developed by the ECAT Working Group, led by the Agency for Clinical Innovation. The group involved expert medical, nursing and allied health representatives from local health districts across NSW. Consensus was reached on all recommendations included within this protocol.
Currency	Due for review: Jan 2026. Based on a regular review cycle.
Feedback	Email ACI-ECIs@health.nsw.gov.au