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 emergency simulation sessions 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)
  • Acidaemia: Bicarbonate (HCO3-) < 15.0mmol/L and/or venous pH < 7.3

 

DKA usually occurs as a result of either absolute insulin deficiency or complete insulin insensitivity.

Therefore the two patient groups 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:

  • Palpitations
  • Nausea
  • Vomiting
  • Sweating
  • Thirst
  • Weight loss
  • Kussmaul breathing

 

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:

  • Tachycardia
  • Hypotension
  • Reduced skin turgor
  • Leg cramps
  • 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 delegate tasks where appropriate
  • All critically unwell patients should have continuous monitoring equipment attached for accurate observations including:
    • Blood pressure
    • 3-lead ECG
    • Oxygen saturations
    • Heart rate
    • Respiratory rate
    • Regular blood glucose measurements
  • Communicate how often you would like these observations to be relayed to you
  • Call for help early using an appropriate SBARR handover structure (check out the guide here)
  • You need to both request investigations and review results 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!

 

Initial steps

You are likely to be called to see this patient either:

  • On the ward 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!

Inspection

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)

 

Interaction

  • 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

 

Preparation

Ensure you have as much information as possible available to you

  • Patient notes
  • Drug charts including diabetes charts!
  • Observations charts

Airway

Assessment

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.

 

Intervention

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 head tilt, chin lift manoeuvre.

2.  If noisy breathing persists, try a jaw thrust.

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.

 

Breathing

Assessment

Oxygen saturation: aim for 94-98%.

Respiratory rate:

  • 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)

 

Examination

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).

 

Investigations

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.

Chest x-ray

 

Intervention

Oxygen

  • Administer oxygen as soon as possible to maximise saturation levels.
    • High-flow oxygen (15 litres) should be administered through a non-rebreathe mask.
  • If the patient is conscious, sit them upright
  • Maintain oxygen saturations between 94-98%

 

Assisted ventilation

  • If your patient is unconscious and their respiratory rate is inadequate (too slow or irregular with big pauses), you can provide assisted ventilation through a bag-valve-mask (BVM).
  • Ventilate at a rate of 12-15 breaths per minute (roughly one every 4 seconds).
  • See our guide to common airway equipment here.

Re-assess after any intervention

 

Circulation

Assessment

Pulse

  • Tachycardia is common in DKA due to fluid depletion and catecholamine release
  • Bradycardia is a late sign, often preceding cardiac arrest

 

Blood pressure

  • Hypotension is common in DKA due to hypovolaemia (secondary to reduced oral intake and vomiting)

 

Examination

  • Your patient may appear clammy/pale
  • You may palpate a fast pulse (tachycardia)
  • Capillary refill time may be normal or sluggish due to hypovolaemia

 

Investigations

Take blood samples

  • Try if possible to collect blood samples during cannulation
  • Full Blood Count – infection and anaemia
  • CRP – infection/inflammation
  • Urea and Electrolytes
    • Acute kidney injury secondary to hypovolaemia
    • Ketoacidosis results in H+ ions moving into cells by displacing potassium. As a result, serum potassium levels rise, resulting in hyperkalaemia
  • Liver Function Tests
  • Serum Glucose – useful for guiding treatment

 

Record an ECG

  • This should not delay your treatment of hypoglycaemia. However, an ECG should be performed at some point, particularly if serum potassium levels are raised.
  • See our guide to recording an ECG here and our guide to interpreting an ECG here

 

Intervention

Secure intravenous access

 

Administer IV fluids

  • Patients with a diagnosis of DKA need fluids to:
    • Restore circulatory volume
    • Clear ketones
    • Correct electrolyte imbalances
    • Perfuse the kidneys
  • 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

 

Disability

Assessment

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.

Assess pupils

  • 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.

Intervention

Reverse hyperglycaemia

  • 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

 

Exposure

Assessment

Inspection

  • 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

  • Urine output will likely be reduced
  • If possible ask the patient when they last passed urine

 

Temperature

  • 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.

 

Intervention

Catheterise

  • 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.

 

Reverse hypothermia

  • Use blankets to re-warm patients who are mild to moderately hypothermic.
  • Consider active re-warming techniques in patients with severe hypothermia.

Re-assess after any intervention

 

Reassess ABCDE

It is essential to continually reassess ABCDE and treat issues as you encounter them. This allows continual reassessment of the response to treatment and early recognition of deterioration.

 

Next steps

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.

 

Review

  • Patient notes
  • Observation charts
  • Fluid charts
  • Investigation findings
  • 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.

 

Document

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.

See our documentation guides here.

 

Discuss

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?

 

References

1. Diabetes UK with the Joint British Diabetes Societies Inpatient Care Group. Management of diabetic ketoacidosis in adults. [LINK]

 

 

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