Chart — Endocrine
Endocrine Crisis Comparison Chart
DKA vs HHS vs thyroid storm vs adrenal crisis vs severe hypoglycemia — triggers, glucose, ketones, temperature, mental status, priority labs, first action, critical do-nots, and NCLEX pearls.
Educational use only. All five conditions are life-threatening emergencies. Always follow institutional protocols, involve the appropriate specialty team, and follow provider orders. This material supports nursing education and exam review. It is not medical advice and is not a substitute for clinical judgment, institutional policy, or medical direction. Always follow facility protocols and current provider orders.
| Feature | DKA Diabetic Ketoacidosis | HHS Hyperosmolar Hyperglycemic State | Thyroid Storm Thyrotoxic Crisis | Adrenal Crisis Addisonian Crisis | Hypoglycemia Severe Hypoglycemic Emergency |
|---|---|---|---|---|---|
| Typical Patient | Type 1 DM; occasionally Type 2 under severe stress or SGLT2 inhibitor | Type 2 DM (often elderly, often undiagnosed); develops over days to weeks | Known Graves' / hyperthyroidism + physiologic trigger (surgery, infection, contrast) | Patient on chronic steroids; known Addison's; post-adrenalectomy; abrupt steroid discontinuation | Insulin or sulfonylurea user; missed meal; alcohol; renal failure; excessive exercise |
| Key Trigger | Missed insulin; infection; new DM diagnosis; alcohol excess | Infection (most common); dehydration; diuretics; steroids; surgery | Surgery, RAI, iodine contrast, infection — in patient with uncontrolled hyperthyroidism | Acute illness/vomiting without dose increase; abrupt steroid discontinuation; surgery without stress dosing | Insulin excess; delayed or skipped meal; sulfonylurea; renal failure (reduced insulin clearance) |
| Glucose | > 250 mg/dL (often 300–600) | > 600 mg/dL (often 800–2000) | Elevated (hyperglycemia from catecholamine surge and cortisol); not the defining lab | Low — hypoglycemia (cortisol deficiency impairs gluconeogenesis) | < 70 mg/dL (Level 1); < 54 mg/dL (Level 2); any level with severe symptoms (Level 3) |
| Ketones / pH | Ketones PRESENT (positive urine or serum); pH < 7.3; anion gap > 12 — ELEVATED ANION GAP METABOLIC ACIDOSIS | Ketones ABSENT or minimal; pH normal (no significant acidosis); hyperosmolality | No ketones; no significant acidosis; elevated LFTs (liver involvement); Burch-Wartofsky score ≥ 45 | No ketones; metabolic acidosis (from hypotension and cellular hypoperfusion); hyponatremia, hyperkalemia | No ketones unless concurrent DKA; normal pH unless prolonged seizure (lactic acidosis from muscle activity) |
| Temperature | Fever if infection; may be normothermic | Fever if infection; may be normothermic | HYPERTHERMIA > 104°F (40°C) — cardinal sign of thyroid storm | Fever if infection triggered crisis; may have hypothermia | Diaphoresis (cold, clammy — adrenergic response); normothermic or mildly hypothermic |
| Mental Status | Alert to confused; level correlates with severity of acidosis; coma in severe | Obtunded → coma — mental status changes (directly related to hyperosmolality) | Agitated → confused → obtunded; psychosis possible; worsening with each hour | Confusion, obtundation, weakness — may mimic acute abdomen | Adrenergic: anxiety, shakiness, diaphoresis; Neuroglycopenic: confusion, slurred speech, seizure, coma |
| Priority Labs | BMP (glucose, K⁺, CO₂), ABG (pH, HCO₃, PCO₂), urine/serum ketones, anion gap, CBC, urine culture if infection suspected | BMP (glucose, BUN/Cr), calculated serum osmolality (2[Na] + Glucose/18 + BUN/2.8), CBC; ketones (to rule out concurrent DKA) | TSH, free T4, free T3, LFTs, CBC, ECG; clinical scoring (Burch-Wartofsky) guides diagnosis | Cortisol (random — treat before getting results if critically ill), ACTH, BMP (Na, K, glucose), CBC, blood cultures if infection | POC glucose immediately; repeat in 15 min after treatment. If unclear etiology: comprehensive metabolic panel, CBC, thyroid, cortisol. |
| First Action | IV Normal Saline 1 L/hr — fluid resuscitation FIRST (or simultaneously with insulin). Check K⁺ before insulin. | IV fluid resuscitation (NS first — patients profoundly dehydrated, 8–10+ L deficit). Correct slowly. | Beta-blocker (propranolol IV) FIRST — controls tachycardia and inhibits T4→T3 conversion. Then PTU → potassium iodide (1h later) → hydrocortisone. | IV Hydrocortisone 100 mg bolus IMMEDIATELY. Do NOT delay for lab confirmation. Then D5NS. | IV access: D50W 25g (50 mL) IV immediately. No IV: Glucagon 1 mg IM or intranasal. Recheck glucose in 15 min. |
| Critical Do NOT | Do NOT give insulin without checking K⁺ first (fatal hypokalemia risk). Do NOT stop insulin when glucose normalizes (clear ketones first). Do NOT use D50W for glucose correction — use D5NS. | Do NOT correct glucose or osmolality too rapidly — cerebral edema risk. Lower glucose no faster than 50–75 mg/dL/hr. | Do NOT give aspirin for fever — displaces T4 from binding proteins (worsens thyrotoxicosis). Do NOT give potassium iodide BEFORE PTU. | Do NOT wait for lab results before giving hydrocortisone — can be fatal. Do NOT abruptly stop steroids in stable patients (this causes crisis). | Do NOT give oral glucose to unconscious or seizing patient (aspiration). Do NOT rely on glucagon in malnourished/alcoholic patients (no glycogen stores). |
| Resolution Criteria | pH > 7.3, HCO₃ > 18, anion gap closed, patient tolerating PO → transition SQ insulin 2h before stopping drip | Glucose < 300, osmolality normalized, mental status improved, tolerating PO fluids → SQ insulin | Heart rate controlled, temperature trending down, mental status improving → transition to oral antithyroid drugs | BP stabilized, glucose normalized, alert → taper IV hydrocortisone; transition to oral maintenance + fludrocortisone | Glucose > 80 mg/dL, patient alert, able to swallow → carbohydrate + protein snack; document; review regimen with provider |
| NCLEX Pearl | Check K⁺ BEFORE insulin. Anion gap acidosis + ketones. IV fluid FIRST. Insulin drip until gap closed, not until glucose normal. | No ketones (vs DKA). Elderly Type 2 DM. Hyperosmolality causes coma. Fluids are the main treatment. | Beta-blocker FIRST. PTU before iodide (1h gap). Acetaminophen NOT aspirin. Thyroid storm = hyperthermia + altered mentation + tachycardia. | Hydrocortisone FIRST — before lab results. D5NS (replaces glucose and volume). Hyperpigmentation = primary (high ACTH). Never stop steroids abruptly. | Treat before notifying. Never oral if unconscious. D50W IV or glucagon IM/nasal. Glucagon needs glycogen stores. Beta-blockers mask adrenergic signs (diaphoresis persists). |
Universal Endocrine Crisis Rules
- Treat first — diagnose second (adrenal crisis, severe hypoglycemia)
- IV access is the first nursing action in any crisis
- Never give insulin without checking potassium first (DKA)
- Never give oral glucose to an unconscious patient
- Aspirin is contraindicated in thyroid storm (use acetaminophen)
Glucose Pattern Summary
Very high glucose (> 600): HHS
High glucose + ketones + acidosis: DKA
High glucose + hyperthermia + tachycardia: Thyroid storm
Low glucose + hyponatremia + hyperkalemia: Adrenal crisis
Low glucose + diaphoresis + altered mentation: Hypoglycemia
Related Resources
Endocrine Crisis Management ReferenceDetailed crisis-by-crisis breakdown — triggers, labs, interventions, resolution, and do-not actions
Open →DKA vs HHS Comparison ChartDeeper DKA vs HHS comparison with full treatment protocol
Open →Adrenal Disorder Comparison ChartCushing's vs Addison's vs adrenal crisis vs pheochromocytoma
Open →Thyroid Disorder Comparison ChartHypothyroidism vs hyperthyroidism vs thyroid storm vs myxedema coma
Open →Standards & sources
Fact-checked Jun 20, 2026This page is written to align with American Diabetes Association (ADA) Standards of Care · American Association of Clinical Endocrinology (AACE). It is an educational summary, not a citation of any single document — always verify specific doses, values, and protocols against current guidelines and your facility policy. How we source content →