Diabetic Ketoacidosis or DKA is a life-threatening condition that you need to be able to recognise and manage in the acute setting. This guide gives an overview of the recognition and immediate management of DKA using the ABCDE approach. You can check out our overview of the ABCDE approach here.
This guide has been created to assist students in preparing for emergencysimulationsessions as part of their training. It is not intended to be relied upon for patient care.
Clinical features of DKA
DKA can present in a variety of different ways. However, diagnosing the condition requires the following 3 key features:
Hyperglycaemia: Blood glucose > 11.0mmol/L or known diabetes mellitus
Ketonaemia: > 3.0mmol/L or significant ketonuria (more than 2+ on standard urine sticks)
DKA usually occurs as a result of either absolute insulin deficiency or complete insulin insensitivity.
Therefore the twopatientgroups who suffer from DKA are:
Type 1 diabetics (absolute insulin deficiency)
Insulin-dependent type 2 diabetics (complete insensitivity to whatever insulin they do still produce)
In DKA the body will produce an increase in counter-regularly hormones such as glucose, cortisol, growth hormones and catecholamines. Blood will become more acidic due to a rise in acid ketones. Therefore symptoms of DKA will include:
Osmotic diuresis due to the hyperglycaemia in DKA will also lead to fluid depletion and electrolyte disturbance. This is additional to fluids lost through vomiting. Therefore, patients will appear clinically dry and will have clinical findings to support this:
Reduced skin turgor
Dry mucous membranes
Reduced urine output
Confusion / drowsiness / coma
Diabetes UK developed thorough guidelines together with the Joint British Diabetes Societies Inpatient Care Group for the management of diabetic ketoacidosis in adults (available online here).
Tips before you begin
Treat all problems as you find them
Re-assess regularly and after every intervention to see if your management is effective
Make use of the team around you to delegatetasks where appropriate
All critically unwell patients should have continuousmonitoring equipment attached for accurate observations including:
Regular blood glucose measurements
Communicate how often you would like these observations to be relayed to you
You need to both requestinvestigations and reviewresults as they become available
You don’t have to memorise everything off by heart, ask for guidelines and algorithms that are relevant (i.e. DKA protocols)
If you would like medications or fluids, these will need to be prescribed
Don’t forget to document everything you have found and done in the patient notes!
You are likely to be called to see this patient either:
Ontheward having become more drowsy and unwell OR
As a new admission to ED
An episode of DKA is often the first presentation of someone with Type 1 Diabetes!
Perform a quick general inspection of the patient to get a sense of how unwell they are:
If the patient is unconscious, check for a pulse and check that the patient is breathing.
If the patient is unconscious or unresponsive and not breathing start the basic life support (BLS) algorithm as per resuscitation guidelines. Call 2222 for help! (see our BLS guide here)
Perform AVPU and assess their consciousness level
How do they look?
What is their breathing like?
Can you smell anything (e.g. acetone on the breath?)
Are there any clues from around the bedside? (look for drug charts, medication, IV lines, monitoring equipment etc)
Introduce yourself to the patient even if they appear unconscious as they may still be able to hear you
If the patient is able to answer questions, ask how they are feeling
Ensure you have as much information as possible available to you
Drug charts including diabetes charts!
Assess the patient’s ability to speak, listen to the patient’s breathing for added sounds and inspect the mouth.
The presence of stridor (a high pitched inspiratory noise) indicates upper airway obstruction. In DKA, this might indicate that your patient’s consciousness level is impaired enough to compromise airway patency.
If you think your patient has a compromised airway you need help ASAP. Put out a crash call immediately as you require urgent anaesthetic input to secure the airway. You can perform some simple airway manoeuvers in the meantime.
Maintaining the airway whilst awaiting senior support
1. Perform a headtilt, chinliftmanoeuvre.
2. If noisy breathing persists, try a jawthrust.
3. If this is still not enough to open up the airway you can consider the use of an airway adjunct:
If your patient is still semi-conscious then consider using a nasopharyngeal (NP)airway.
If your patient is able to tolerate an oropharyngeal (OP, or Guedel) airway then you can use one of these. However, this indicates that your patient is seriously unwell as they no longer have a gag reflex.
Re-assess after any intervention
If your patient starts to improve throughout your assessment, they may no longer be able to tolerate the OP airway and you should remove it as soon as possible to prevent gagging/aspiration.
Oxygen saturation: aim for 94-98%.
Impaired consciousness may lead to a reduced respiratory rate (bradypnoea).
DKA is associated with Kussmaul breathing
Kussmaul breathing is deep, laboured breaths that occur in due to metabolic acidosis (as the body is trying to expire as much CO2 as possible, in an attempt to maintain pH)
Auscultate both lungs:
Reduced air-entry bilaterally suggests significant airway compromise and the need for critical care input.
Added sounds such as crackles or wheeze may suggest an underlying infection. In patients with a diagnosis of diabetes already, there is usually a precipitating event for their DKA which is often an infection (typically chest or urinary source).
Arterial blood gas
An arterial blood gas may be useful to quantify the degree of hypoxia if your patient has very low oxygen saturations, however, it should not delay the treatment of DKA.
A blood gas can also give you a quick blood glucose level, however, you should always get a more accurate serum sample to confirm the ABG result. Many point-of-care glucose measurement devices will struggle to obtain accurate readings if the glucose is very high or very low.
A chest x-ray is not immediately indicated if all your examination findings are normal.
Use NaCl 0.9% or Hartmann’s solution for initial fluid resuscitation
Titrate fluids based on the level of haemodynamic instability, however, be aware that patients with DKA will likely require large volumes of fluids.
Ask for your medical school/hospital’s guidelines for the treatment of DKA which will specify how they wish you to administer fluids.
Re-assess after any intervention
Blood glucose level (+ ketones)
If you were aware that your patient was at risk of DKA then it would be appropriate to measure their capillary blood glucose as soon as possible. If you have an extra person, you could ask them to do a finger-prick test whilst the Airway, Breathing and Circulation are being assessed. However, it is vital to secure their airway and assess their breathing as problems with airway, breathing and circulation will kill the patient more rapidly than hyperglycaemia will.
What size are they?
Are they equal?
Are they reactive to light?
Assess level of consciousness – AVPU/GCS
The above Airway, Breathing and Circulation problems can all alter the patient’s neurological status because of decreased cerebral perfusion, causing the patient to be confused or drowsy.
A formal record of your patient’s consciousness level will be really useful for tracking progress and changes throughout treatment.
Ask for your medical school/hospital’s guideline for the treatment of DKA.
A fixed rate intravenous insulin infusion (FRIII) is required.
You will need to know the patient’s body weight or be able to estimate it to calculate the FRIII rate (Actrapid 0.1 units/per kg of body weight/hr).
You will also need to know your patient’s potassium level and measure this throughout treatment as it is likely to drop quickly with insulin treatment and will need to be replaced.
Re-assess after any intervention
We routinely expose all unwell patients to make sure that we aren’t missing anything.
In our unconscious patient with an unknown history, we might find sites of self-injection (e.g. areas of lipohypertrohy) which may tell us we are dealing with a patient with diabetes.
Urine output will likely be reduced
If possible ask the patient when they last passed urine
Someone who has been unconscious for some time might be hypothermic.
Hyperthermia might indicate an underlying infection which could contribute to the DKA but it can also be part of the catecholamine response.
If necessary, catheterise your patient so you can monitor their urine output and use this to guide intravenous fluid replacement.
Take a urine dipstick as part of the procedure to screen for evidence of infection and assess for ketones.
Use blankets to re-warm patients who are mild to moderately hypothermic.
Consider activere-warming techniques in patients with severe hypothermia.
Re-assess after any intervention
It is essential to continually reassessABCDE and treat issues as you encounter them. This allows continual reassessment of the response to treatment and early recognition of deterioration.
Well done! Your patient’s blood sugars are falling and they are starting to feel much better. There are just a few more things to do…
Take a history
Now your patient might be able to give you a detailed history of what has happened. How have they been over the last few days? Are there any clues from the history as to what has precipitated this episode of DKA? If your patient is still confused you might be able to get a collateral history from staff or family members as appropriate. Check out the history taking guides here.
Additionally, make sure to check the medications you have just prescribed and what they are normally taking. It might be that their current regime is inappropriate for them.
It is really important that you document your initial ABCDE findings, any interventions you made and the response the patient had to those interventions. Write down important information you have elicited from the history taking.
You must consider why your patient has developed DKA and take steps to prevent his from happening again. Discuss the patient with your seniors and the diabetic team. Your patient will likely need a review from the diabetes specialist nurses.
As a junior doctor it would be appropriate to give an SBARR handover outlining your assessment and actions, and to discuss the following:
Are there any further assessments or interventions required?
Does the patient need a referral to HDU/ICU?
Should the patient be referred for a review by a specialist doctor (i.e. endocrinologist)?
Should any changes be made to the management of their underlying conditions?
1. Diabetes UK with the Joint British Diabetes Societies Inpatient Care Group. Management of diabetic ketoacidosis in adults. [LINK]