Severe hypoglycemia — a very low glucose with altered consciousness, seizure, or inability to swallow — treat per protocol (glucagon/IV dextrose per order) and escalate/transfer.

DKA / hyperosmolar state — very high glucose with ketones, Kussmaul breathing, dehydration, or altered mentation — escalate/transfer.

Severe electrolyte disturbance — symptomatic hyper/hypokalemia or hyponatremia (arrhythmia, weakness, confusion, seizure) — escalate/transfer.

Thyroid storm or myxedema signs — escalate/transfer per severity.