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''Diabetic ketoacidosis'' (more common)
hyperglycaemia (usually but not always), ketonaemia (>3mmol/l),
ketonuria (++ or more) and metabolic acidosis (ph <7.3,
venous bicarb <15mmol/l)
occurs within 24-48 hours of lack of insulin, can occur in type 2 with
severe intercurrent illness (sepsis or MI)
ketone level indicates severity better than glc level (may have glc
10-14 and severe DKA)

''Hyperglycaemic hyperosmolar syndrome'' (10-15% type 2 emergency)
hyperglycaemia, drowsy, dehydration, ?thirsty, NOT ketonaemia or
ketonuria, osmolality >320
takes 1-2 weeks to develop
coma, convulsions, focal neurology are possible
signs - drowsy, tachycardia, hypotensive, poor skin turgor
usually in elderly, prognosis is worse than DKA (due to co-morbidities?)
but unrelated to severity of hyperglyc

''Physiology''
- insulin deficiency occurs with increased counterreg hormones glucagon,
cortisol, GH, adrenaline
- Hyperglycaemia - from dec peripheral glc uptake and inc glycogen
breakdown and gluconeogenesis (inc protein breakdown)
leads to osmotic diuresis - loss of water and electrolytes (esp Na and
K)
- ketosis - n/v, abdo pain, mvt K out of ICF
- In HHS - insulin levels are enough to prevent lipolysis (ketones) but
not hyperglycaemia (usually type 2)
slower dvlpment but fluid losses may be huge (higher than DKA), 
lactic acidosis may develop 2ndary to dehydration 

''Management DKA''
Always in 2ndary care
May give IV fluids plus bolus insulin if transfer delay but not routine.

If on insulin pt needs to be able to test blood glc and ketones (Blood
or urine), have soluble insulin and be able to follow "sick day rules".
rules
never stop insulin
measure glc and ketones 2-4hrly 
- if glc trend is over 7, then inc usual insulin by 10% per dose
- if ketones - give 20% of 24hr insulin dose as extra dose (repeat 2-4
hrly)
drink glc drink if not eating
if signs of DKA - hospital

''Management of HHS''
Osmolality = 2(Na+K)+glc+urea
different to DKA as high osmolality, very high glc and no ketones

''Hypoglycaemia''
severe - needs 3rd party to sort out - pts on insulin or sulphylureas
10% type 1 per year less in type 2
below 4 counterreg hormones inc
autonomic (tremor, sweating, hunger, palpitations, aggression) and neuro
dysfunction (confusion, visual disturb, tingling round lips, dec
concentration) below 3 - severe below 1.5 (fits, focal signs, TIA, )
inc with coeliac, addisons, renal disease, cirrhosis, pancreatectomy
not with cushings
only insulin and sulphonylureas predispose to hypo
with sulphonylurea risk may be for 24-48 hours or longer
''Management''
If conscious - short and then long acting CHO
If unconscious - either 10% or 20% glc IV, or glucagon (1mg IM or SC, SE n/v abdo pain or hypotension)
Excersize - inc insulin sensitivity and depletes muscle and liver stores of glycogen, so risk of hypo continues for up to 18 hours - so dec next insulin dose too.
If no recovery - glc infusion and admit to seek cause