Signs and Symptoms
- General malaise
- Polydipsia
- Polyuria
- Abdominal pain, nausea, vomiting
- Altered mental status
- Chest pain
- Fever if there is an infection
History
- Medication noncompliance
- Change in diabetic medications (e.g., change in dosage)
- Change in diet or eating habits
- Recent illness
Physical Exam
- Hypotension if volume is down
- Tachycardia
- Dry oral mucous membrane
- Altered mental status
- Tachypnea
- Abdominal tenderness
Essential Workup
- Electrolytes, BUN/creatinine, glucose
- CBC
- β-hydroxybutyrate
- ECG
- VBG
- Urine
- Imaging studies (e.g., CXR if pneumonia is suspected)
- Blood cultures and urine culture if infection is suspected
Diagnostic Tests & Interpretation
Lab
- Glucose:
- DKA: Usually is <800 mg/dL, can be higher if the patient is comatose
- Hyperosmolar hyperglycemic state (HHS): >1,000 mg/dL with no or minimal ketones
- Sodium:
- Hyponatremia: Water shifts from inside the cell to outside the cell secondary to hyperglycemia
- Corrected sodium = measured sodium + [1.6 (glucose - 100)/100]
- Potassium:
- Normal, low, or high, but patient is likely to be whole-body depleted despite serum levels
- Usually appears elevated, but rapidly corrects with rehydration and correction of acidosis
- Need to anticipate pending hypokalemia as patient improves
- Anion gap:
- Na - (Cl + HCO3)
- Anion gap >12 in DKA
- Serum ketones:
- β-hydroxybutyrate is preferred (more sensitive and cost effective compared to acetone)
- Can still be elevated in a DKA patient with normal or mild elevated glucose (useful in making the diagnosis of DKA)
- Urine ketones:
- Sensitive (98% sensitivity) but not specific (35% specificity)
- Other reasons such as dehydration can also elevate urine ketones
- Bicarbonate:
Imaging
- Order as clinically indicated (e.g., CXR if pneumonia is suspected)
- ECG to check for:
- MI
- Dysrhythmias
- Abnormal intervals
- Abnormal T-wave morphology
- U-waves
Differential Diagnosis
Not limited to the following:
- HHS
- Alcoholic ketoacidosis
- Sepsis
- Salicylate toxicity
- Surgical abdomen (e.g., appendicitis)
Prehospital
Initial Stabilization/Therapy
- Airway, breathing, circulation
- Cardiac Monitor
- ECG
- POCT glucose
- IVF bolus
ED Treatment/Procedures
- IVF (Be cautious not to overload patients with CAD or renal failure):
- NS: Initial bolus (1-2 L) in the first hour
- After the second liter:
- If corrected sodium is low, with mild dehydration, use NS at 250-500 mL/hr
- If corrected sodium is high or normal, with mild dehydration, use ½ NS at 250-500 mL/hr
- If serum glucose is <200 mg/dL
- Insulin (Be mindful to correct hypokalemia accordingly):
- Mild DKA
- Subcutaneous lispro 0.3 U/kg initial dose, then 0.1 U/kg q1h, or
- Follow protocol at your institution
- Moderate to severe DKA:
- IV regular insulin at 0.1 U/kg/hr, or
- Follow protocol at your institution
- Serum glucose is <200 mg/dL:
- Decrease IV regular insulin to 0.02-0.05 U/kg/hr
- Potassium (established normal renal function)
- If potassium is <5.3 mEq/L, add 20-30 mEq of K in each liter of fluid to maintain potassium in normal range
- If potassium is <3.3 mEq/L, hold insulin until potassium is ≥3.3 mEq/L to avoid worsening hypokalemia and life-threatening dysrhythmias
- Administer potassium at 20-30 mEq/hr by mixing 40-60 mEq of potassium in ½ NS or follow your institution protocol
- Sodium bicarbonate:
- No evidence in improving clinical outcomes
- However, some authors recommended sodium bicarbonate if the pH is <6.9 (to improve cardiac contractility)
- Magnesium:
- Correct hypomagnesemia (<1.2 mg/dL) with IV magnesium sulfate (2 g is the usual dose)
- Phosphorus:
- Not routinely replaced during initial ED resuscitation
- May supplement if <1 mg/dL with symptomatic muscle weakness
- Administered as potassium phosphate
Pediatric Considerations |
- Fluids:
- Average fluid deficit is 100 mL/kg
- Initial 10-20 mL/kg bolus of 0.9% NS to restore intravascular volume
- May repeat once in severely dehydrated children
- Should not exceed 40-50 mL/kg of fluid in first 4 hr of therapy
- Replace remainder of deficit at 1.5-2 times maintenance over 24-36 hr
- Overzealous fluid administration is thought to contribute to cerebral edema:
- Occurs in 1-2% of children with DKA
- Causes 31% of deaths associated with DKA
- Exact causes unclear
- Suspect with coma, fluctuating mental status, bradycardia, HTN, severe headache, decreased urine output, or quickly falling corrected Na+ or osmolality to below normal levels
- Mannitol: 0.25-1 g/kg IV over 30 min should be given immediately and can be repeated hourly
- Fluid rate should be decreased and other supportive measures instituted
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Medication
Insulin infusion: 100 units of regular insulin in 100 mL of NS. Administer at 0.1 U/kg/hr
Disposition
Admission Criteria
- Severe DKA: ICU or step-down unit
- Moderate DKA with stable vital signs: Regular medical floor
- Mild DKA: Observation unit
Discharge Criteria
- Resolution of DKA
- Stable vital signs
- Able to tolerate oral intake
Follow-up Recommendations
Close follow-up with primary care physician and /or endocrinologist
- BeltranG. Diabetic emergencies: New strategies for an old disease . Emerg Med Pract. 2014;16(6):1-20.
- TrachtenbargDE. Diabetic ketoacidosis . Am Fam Physician. 200571(9):1705-1714.
- TranTT, PeaseA, WoodAJ, et al. Corrigendum: Review of evidence for adult diabetic ketoacidosis management protocols . Front Endocrinol (Lausanne). 2017;8(106):1-13.
The authors gratefully acknowledge Joseph M. Weber for his contribution to the previous edition of this chapter.