Diabetes and endocrinology emergencies

On this page​​

1. Adult Diabetes and Endocrinology
1. Gestational diabetes
2. Other diabetes mellitus types
3. Type 1 diabetes
4. Type 2 diabetes
5. Adrenal disorders
6. Osteoporosis and metabolic bone disease
7. Pituitary disorders
8. Thyroid and parathyroid disorders
2. ​Paediatric Diabetes and Endocrinology
1. Type 1 diabetes
2. Type 2 diabetes
3. Adrenal disorders
4. Calcium and bone disorders
5. Growth disorders
6. Pituitary disorders
7. Pubertal disorders
8. ​Thyroid disorders

Adult patients (aged 16 years or over) ​

Gestational diabetes

• Acute, severe hyperglycaemia or hypoglycaemia requiring immediate assistance
• Diabetic ketoacidosis
• Gestational diabetes with severe vomiting​

Other diabetes mellitus types

• Acute, severe diabetes-related end-organ complication (e.g. suspected acute coronary syndrome, cerebrovascular event, infected foot ulcer with systemic features, new vision loss, or renal failure)
• Clinical features suggesting diabetic ketoacidosis or euglycaemic ketoacidosis (i.e. clinical dehydration, rapid or laboured [Kussmaul] breathing, recurrent vomiting, reduced level of consciousness, or haemodynamically compromised with tachycardia or hypotension)
• Diabetes-related foot ulceration with absent pulses
  Note: refer to a vascular surgeon or high-risk foot service
• Diabetes-related foot ulceration with features of severe or systemic infection
  Note: refer immediately to emergency department and/or high-risk foot service
• High ketones unresponsive to initial management (i.e. moderate or greater result on urine testing or > 1.5 mmol/L
  on finger prick blood test)
• Recurrent, persistent vomiting for > 4 hours preventing oral intake and hydration
• Severe hypoglycaemia requiring third party assistance including that occurring with loss of consciousness
  Note: referral to endocrinologist or diabetes service is indicated for rapid access outpatient appointment within 24 hours. If no medical-led specialist outpatient service is available, present to an emergency department.
• Suspected or symptomatic hyperosmolar hyperglycaemic state (HHS) (i.e. polyuria, polydipsia, altered mental state, dehydration) with acute illness and/or persistent hyperglycaemia
• Suspected or diagnosed active Charcot neuro-osteo-arthropathy (i.e. clinical signs of inflammation, particularly redness, heat and/or swelling, in the neuropathic foot)
  Note: same-day referral to a high-risk foot service (or similar service to manage Charcot foot)​

Type 1 diabetes

• Acute, severe diabetes-related end-organ complication (e.g. suspected acute coronary syndrome, cerebrovascular event, infected foot ulcer with systemic features, new vision loss, or renal failure)
• Clinical features suggesting diabetic ketoacidosis or euglycaemic ketoacidosis (i.e. clinical dehydration, rapid or laboured [Kussmaul] breathing, recurrent vomiting, reduced level of consciousness, or haemodynamically compromised with tachycardia or hypotension)
• Diabetes-related foot ulceration with absent pulses
  Note: refer to a vascular surgeon or high-risk foot service
• Diabetes-related foot ulceration with features of severe or systemic infection
  Note: refer immediately to emergency department and/or high-risk foot service
• High ketones unresponsive to initial management
  (i.e. moderate or greater result on urine testing or > 1.5 mmol/L on finger prick blood test)
• New diagnosis of type 1 diabetes suspected with clinical instability (e.g. rapid weight loss, polyuria, polydipsia and
  blood glucose > 15.0 mmol/L)
• Pre-existing type 1 diabetes with new onset, persistent hyperglycaemia and clinically unwell (i.e. blood glucose level
  > 15.0 mmol/L for > 4 hours)
• Pregnant patient with persistent blood glucose level of > 10.0 mmol/L and/or blood ketones
  > 0.6 mmol/L unresponsive to initial management
• Pregnant patient with persistent blood glucose level of < 3.5 mmol/L (confirmed by finger prick test, where possible) unresponsive to initial management
• Recurrent, persistent vomiting for > 4 hours preventing
  oral intake and hydration
• Severe hypoglycaemia requiring third party assistance including that occurring with loss of consciousness
  Note: referral to endocrinologist or diabetes service is indicated for rapid access outpatient appointment within 24 hours. If no medical-led specialist outpatient service is available, present to an emergency department.
• Suspected or diagnosed active Charcot neuro-osteo-arthropathy (i.e. clinical signs of inflammation, particularly redness, heat and/or swelling, in the neuropathic foot)
  Note: same-day referral to a high-risk foot service (or similar service to manage Charcot foot)​

Type 2 diabetes

• Acute, severe diabetes-related end-organ complication
  (e.g. suspected acute coronary syndrome, cerebrovascular event, infected foot ulcer with systemic features, new vision loss, or renal failure)
• Clinical features suggesting diabetic ketoacidosis (even if glucose is normal) (i.e. clinical dehydration, rapid or laboured [Kussmaul] breathing, recurrent vomiting, reduced level of consciousness, haemodynamically compromised with tachycardia or hypotension, urine ketones +++, or > 1.5 mmol/L blood ketones)
• Diabetes-related foot ulceration with absent pulses
  Note: refer to a vascular surgeon or high-risk foot service
• Diabetes-related foot ulceration with features of severe or systemic infection
  Note: refer immediately to emergency department and/or high-risk foot service
• High ketones unresponsive to initial management (i.e. moderate or greater result on urine testing or > 1.5 mmol/L
  on finger prick blood test)
• Pregnant patient with persistent blood glucose level of
  > 10.0 mmol/L and/or blood ketones > 0.6 mmol/L unresponsive to initial management
• Pregnant patient with persistent blood glucose level of
  < 3.5 mmol/L (confirmed by finger prick test, where possible) unresponsive to initial management
• Recurrent, persistent vomiting for > 4 hours preventing
  oral intake and hydration
• Severe hypoglycaemia requiring third party assistance including that occurring with loss of consciousness
  Note: referral to endocrinologist or diabetes service is indicated for rapid access outpatient appointment within 24 hours. If no medical-led specialist outpatient service is available, present to an emergency department.
• Suspected or diagnosed active Charcot neuro-osteo-arthropathy (i.e. unilateral foot condition with features of peripheral neuropathy, hyperaemia, increased foot skin temperature by 2 degrees or above, restricted joint range of motion, changes in foot shape, oedema, pain and/or bounding pulses)
  Note: same-day referral to a high-risk foot service (or similar service to manage Charcot foot)
• Suspected or symptomatic hyperosmolar hyperglycaemic state (HHS) (i.e. polyuria, polydipsia, altered mental state, dehydration) with acute illness and/or persistent hyperglycaemia
• Unable to tolerate oral fluids and blood glucose levels continue to drop during sick day management
• Unresolved severe hypoglycaemia despite treatment
  Note: patient also should be referred to a medical practitioner for review of diabetes type, ongoing management and driving safety

Adrenal disorders

• Hypopituitarism with haemodynamic compromise or systemic symptoms
• Symptomatic severe hypertension > 180/110 mmHg due to suspected hormonal excess (e.g. phaeochromocytoma,
  primary aldosteronism)
• Suspected or confirmed acute adrenal insufficiency
  (as indicated by hypotension, vomiting, hyponatraemia, hyperkalaemia, anorexia and/or nausea)

Osteoporosis and metabolic bone disease

• Acute anterior uveitis on bisphosphonates (e.g. erythema, photophobia, blurred vision)
  Note: urgent ophthalmology assessment is indicated
• Acute, severe hypophosphatemia
• Radiologically suspected or confirmed atypical femoral fracture
  Note: subsequent endocrinology or rheumatology review may be indicated
• Severe, symptomatic hypocalcaemia (albumin-corrected serum calcium < 1.9 mmol/L)
  due to metabolic bone disease or its treatment (e.g. denosumab-related, hypoparathyroidism such as post-thyroidectomy or spontaneous, severe vitamin D deficiency)
• Severe, symptomatic hypercalcaemia (albumin-corrected serum calcium > 3.0 mmol/L)
  due to metabolic bone disease or its treatment (e.g. hyperparathyroidism, vitamin D toxicity, teriparatide therapy)
• Vertebral fracture following delay or recent discontinuation of denosumab
  Note: refer to neurosurgery if neurological symptoms
• Vertebral fracture with severe pain or signs of neurological compromise​

Pituitary disorders

• New onset adrenal insufficiency or hypopituitarism
• Suspected or confirmed arginine vasopressin deficiency (AVP-D; previously known as cranial diabetes insipidus) with hypernatraemia > 150 mmol/L or hyponatraemia < 125 mmol/L with AVP-D already on treatment
• Suspected pituitary tumour with any of the following features:
• Acute new visual field defect (often initially unilateral temporal field loss progressing to classic bitemporal superior quadrantanopia or hemianopia)
• Hyponatraemia < 125 mmol/L
• Neurological signs or symptoms
• Ophthalmoplegia (pituitary apoplexy)
• Symptomatic cortisol insufficiency
• Thunderclap headache​

Thyroid and parathyroid disorders

• Agranulocytosis or neutropenic sepsis in patient taking carbimazole or propylthiouracil
• Any symptoms suggestive of hypocalcaemia post-thyroid or post-parathyroid surgery
• Thyroid mass with any of the following features:
• Airway compromise
• Breathing difficulty
• Drooling
• Haemoptysis
• Severe odynophagia
• Stridor
• Sudden increase in size or pain over days to weeks
• Sudden voice change
• Corrected serum calcium > 3.0 mmol/L with symptomatic hypercalcaemia (e.g. nausea and vomiting or volume depletion, alteration in mental status, or acute kidney injury)
• Corrected serum calcium > 3.5 mmol/L
• Corrected serum calcium < 1.9 mmol/L with symptomatic hypocalcaemia (e.g. seizures or tetany)
• Hyperthyroidism complicated by cardiac or respiratory compromise, or other indications of severe illness (i.e. fever, vomiting, labile blood pressure or altered mental state)
• Hyperthyroidism with hypokalaemia and paralysis
• Reduced visual acuity in Graves' disease
  Note: refer to ophthalmology state-wide referral criteria
• Suspected myxoedema coma

Paediatric patients (aged 0 to 15 years)

Type 1 diabetes

• Concerns of ketoacidosis with known type 1 diabetes and
  any of the following symptoms or results:
• > 2 vomiting episodes
• Abdominal pain
• Altered conscious state
• Headache
• Inability to eat (even if not vomiting)
• Ketones; blood > 1.5 mmol, urine moderate or large
• Shortness of breath
• Systemic symptoms (i.e. fever, lethargy)
• Known type 1 diabetes with any of the following features:
• Persistent vomiting with hypoglycaemia or hyperglycaemia or inability to tolerate
  oral fluids
• Severe hypoglycaemia (i.e. coma, convulsions, altered consciousness)
• New diagnosis or suspicion of type 1 diabetes as indicated by any of the following symptoms or results:
• HbA1c > 6.5%
• Oral glucose tolerance test (OGTT) with fasting blood glucose level > 7.0 mmol/L and/or 2 hours > 11.1 mmol/L
• Polyuria and/or polydipsia
• Random blood glucose level > 11.0 mmol/L​

Type 2 diabetes

• Known type 2 diabetes with any of the following features:
• Abdominal pain
• Altered conscious state
• Ketones; blood > 1.5 mmol/L, urine moderate or large
• Persistent vomiting with hypoglycaemia or hyperglycaemia or inability to tolerate
  oral fluids
• Severe hypoglycaemia (i.e. coma, convulsions, altered consciousness)
• Vomiting
• New diagnosis of or suspicion for type 2 diabetes as indicated by any of the following features:
• HbA1c > 6.5%
• Oral glucose tolerance test (OGTT) with fasting blood glucose level > 7.0 mmol/L and/or 2 hours > 11.1 mmol/L
• Polyuria and/or polydipsia
• Random blood glucose level > 11.0 mmol/L

Adrenal disorders

• Adrenal crisis (i.e. haemodynamic compromise) associated
  with vomiting, and/or hyponatraemia, and/or hypoglycaemia resulting in unconsciousness or seizure
• Phaeochromocytoma in crisis with uncontrolled hypertension
• Severe and symptomatic (e.g. headaches) hypertension, or
  high or fluctuating blood pressure with headaches, visual disturbance or other neurological symptoms
• Suspected or confirmed new diagnosis of acute adrenal insufficiency
• Suspected pituitary mass (e.g. symptoms of visual field loss or central nervous system signs)
  Note: refer to pituitary disorders state-wide referral criteria

Calcium and bone disorders

• Corrected serum calcium < 1.8 mmol/L or ionised calcium
  < 0.9 mmol/L
• Corrected serum calcium < 2.0 mmol/L with symptoms
  (e.g. seizures, cardiac arrhythmias, tetany, paraesthesia)
• Corrected serum calcium ≥ 3.0 mmol/L, with or without symptoms of hypercalcaemia
  (e.g. cardiac arrhythmias, vomiting, altered mental state)​

Growth disorders

• Myxoedema coma
• Suspected adrenal crisis or first diagnosis of adrenal insufficiency, including unexplained hyponatramia, hypoglycaemia and or myxoedema coma
• Suspected pituitary mass (e.g. symptoms of visual field loss or central nervous system signs)
  Note: refer to pituitary disorders paediatric state-wide referral criteria​

Pituitary disorders

• Hypoglycaemia in which adrenal insufficiency and/or growth hormone deficiency is suspected as the cause
• New onset or suspected diabetes insipidus (anti-diuretic hormone deficiency or resistance), including unexplained hypernatraemia and dehydration
• Suspected adrenal crisis or first diagnosis of adrenal insufficiency
• Suspected pituitary mass with or without neurological symptoms and visual signs (e.g. headaches, visual field loss, blurred vision)
• Vomiting or altered level of consciousness with known adrenal insufficiency​

Pubertal disorders

• Neonatal differences of sexual development
• Suspected pituitary mass (e.g. symptoms of visual field loss or central nervous system signs)
  Note: refer to pituitary disorders paediatric state-wide referral criteria​

Thyroid disorders

• Agranulocytosis in a child or young person taking carbimazole or propylthiouracil
• Hyperthyroidism complicated by cardiac, respiratory compromise, pregnancy, or other indications of severe illness (fever, vomiting, labile blood pressure, altered mental state)
• Hyperthyroidism with hypokalaemia or paralysis
• Neonatal Grave's disease
• Neonate with abnormal newborn screening test
  Note: emergency medical advice via phone is indicated
• Possible tracheal or superior vena cava obstruction from retrosternal thyroid enlargement
• Stridor associated with a thyroid mass
• Suspected myxoedema coma (altered consciousness, hypothermia, fluid overload, bradycardia, hyponatraemia)​