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This guide provides an overview of the recognition and immediate management of diabetic ketoacidosis (DKA) using an ABCDE approach.
The ABCDE approach can be used to perform a systematic assessment of a critically unwell patient. It involves working through the following steps:
- Airway
- Breathing
- Circulation
- Disability
- Exposure
Each stage of the ABCDE approach involves clinical assessment, investigations and interventions. Problems are addressed as they are identified and the patient is re-assessed regularly to monitor their response to treatment.
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.
Background
Aetiology
DKA is characterised by:
- Hyperglycaemia: blood glucose > 11.0mmol/L or known diabetes mellitus
- Ketonaemia: ketones > 3.0mmol/L or significant ketonuria (more than 2+ on standard urine sticks)
- Acidosis: bicarbonate (HCO3-) < 15.0mmol/L and/or venous pH < 7.3
DKA can be caused by either:
- Absolute insulin deficiency (e.g. type 1 diabetes)
- Complete insulin insensitivity (e.g. insulin-dependent type 2 diabetes)
Symptoms
Typical symptoms of DKA include:
- Palpitations
- Nausea
- Vomiting
- Sweating
- Thirst
- Weight loss
- Leg cramps
Clinical signs
Typical clinical signs of DKA include:
- Tachycardia
- Hypotension
- Reduced skin turgor
- Dry mucous membranes
- Reduced urine output
- Altered consciousness (e.g. confusion, coma)
- Kussmaul breathing
Tips before you begin
General tips for applying an ABCDE approach in an emergency setting include:
- Treat all problems as you discover them.
- Re-assess regularly and after every intervention to monitor a patient’s response to treatment.
- Make use of the team around you by delegating tasks where appropriate.
- All critically unwell patients should have continuous monitoring equipment attached for accurate observations.
- Clearly communicate how often would you like the patient’s observations relayed to you by other staff members.
- If you require senior input, call for help early using an appropriate SBARR handover structure.
- Review results as they become available (e.g. laboratory investigations).
- Make use of your local guidelines and algorithms in managing specific scenarios (e.g. acute asthma).
- Any medications or fluids will need to be prescribed at the time (in some cases you may be able to delegate this to another member of staff).
- Your assessment and management should be documented clearly in the notes, however, this should not delay initial clinical assessment, investigations and interventions.
Initial steps
Acute scenarios typically begin with a brief handover from a member of the nursing staff including the patient’s name, age, background and the reason the review has been requested.
You may be asked to review a patient with DKA due to confusion, reduced level of consciousness, tachycardia, hypotension and/or vomiting.
Introduction
Introduce yourself to whoever has requested a review of the patient and listen carefully to their handover.
Interaction
Introduce yourself to the patient including your name and role.
Ask how the patient is feeling as this may provide some useful information about their current symptoms.
Preparation
Make sure the patient’s notes, observation chart and prescription chart are easily accessible.
Ask for another clinical member of staff to assist you if possible.
If the patient is unconscious or unresponsive, start the basic life support (BLS) algorithm as per resuscitation guidelines.
Airway
Clinical assessment
Can the patient talk?
Yes: if the patient can talk, their airway is patent and you can move on to the assessment of breathing.
No:
- Look for signs of airway compromise: these include cyanosis, see-saw breathing, use of accessory muscles, diminished breath sounds and added sounds.
- Open the mouth and inspect: look for anything obstructing the airway such as secretions or a foreign object.
Interventions
Regardless of the underlying cause of airway obstruction, seek immediate expert support from an anaesthetist and the emergency medical team (often referred to as the ‘crash team’). In the meantime, you can perform some basic airway manoeuvres to help maintain the airway whilst awaiting senior input.
Head-tilt chin-lift manoeuvre
Open the patient’s airway using a head-tilt chin-lift manoeuvre:
1. Place one hand on the patient’s forehead and the other under the chin.
2. Tilt the forehead back whilst lifting the chin forwards to extend the neck.
3. Inspect the airway for obvious obstruction. If an obstruction is visible within the airway, use a finger sweep or suction to remove it.
Jaw thrust
If the patient is suspected to have suffered significant trauma with potential spinal involvement, perform a jaw-thrust rather than a head-tilt chin-lift manoeuvre:
1. Identify the angle of the mandible.
2. With your index and other fingers placed behind the angle of the mandible, apply steady upwards and forward pressure to lift the mandible.
3. Using your thumbs, slightly open the mouth by downward displacement of the chin.
Oropharyngeal airway (Guedel)
Airway adjuncts are often helpful and in some cases essential to maintain a patient’s airway. They should be used in conjunction with the maneuvres mentioned above as the position of the head and neck need to be maintained to keep the airway aligned.
An oropharyngeal airway is a curved plastic tube with a flange on one end that sits between the tongue and hard palate to relieve soft palate obstruction. It should only be inserted in unconscious patients as it is otherwise poorly tolerated and may induce gagging and aspiration.
To insert an oropharyngeal airway:
1. Open the patient’s mouth to ensure there is no foreign material that may be pushed into the larynx. If foreign material is present, attempt removal using suction.
2. Insert the oropharyngeal airway in the upside-down position until you reach the junction of the hard and soft palate, at which point you should rotate it 180°. The reason for inserting the airway upside down initially is to reduce the risk of pushing the tongue backwards and worsening airway obstruction.
3. Advance the airway until it lies within the pharynx.
4. Maintain head-tilt chin-lift or jaw thrust and assess the patency of the patient’s airway by looking, listening and feeling for signs of breathing.
Nasopharyngeal airway (NPA)
A nasopharyngeal airway is a soft plastic tube with a bevel at one end and a flange at the other. NPAs are typically better tolerated in patients who are partly or fully conscious compared to oropharyngeal airways. NPAs should not be used in patients who may have sustained a skull base fracture, due to the small but life-threatening risk of entering the cranial vault with the NPA.
To insert a nasopharyngeal airway:
1. Check the patency of the patient’s right nostril and if required (depending on the model of NPA) insert a safety pin through the flange of the NPA.
2. Lubricate the NPA.
3. Insert the airway bevel-end first, vertically along the floor of the nose with a slight twisting action.
4. If any obstruction is encountered, remove the tube and try the left nostril.
Other interventions
If the patient has clinical signs of anaphylaxis (e.g. angioedema, rash) commence appropriate treatment as discussed in our anaphylaxis guide.
CPR
If the patient loses consciousness and there are no signs of life on assessment, put out a crash call and commence CPR.
Re-assessment
Make sure to re-assess the patient after any intervention.
Breathing
Clinical assessment
Observations
Review the patient’s respiratory rate:
- A normal respiratory rate is between 12-20 breaths per minute.
- Patients with DKA may develop deep, laboured breathing (known as Kussmaul breathing) in a response to metabolic acidosis (i.e. respiratory compensation).
Review the patient’s oxygen saturation (SpO2):
- A normal SpO2 range is 94-98% in healthy individuals and 88-92% in patients with COPD who are at high-risk of CO2 retention.
- Hypoxaemia may occur due to aspiration or bradypnoea in the context of severe DKA.
Auscultation
Auscultate the chest to screen for evidence of respiratory pathology (e.g. unilateral coarse crackles may be present if the patient has pneumonia which may have been the precipitant for DKA).
Investigations and procedures
Arterial blood gas
An arterial blood gas (ABG) can provide lots of useful information to guide management including:
- PaO2: may be reduced in the context of pneumonia (e.g. DKA precipitated by a respiratory infection).
- PaCO2: may be low in the context of DKA due to respiratory compensation as a result of metabolic acidosis.
- pH: low in the context of DKA due to the presence of acidic ketones.
- HCO3-: low in the context of DKA due to metabolic acidosis.
Chest X-ray
A chest X-ray may be indicated if abnormalities are noted on auscultation (e.g. reduced air entry, coarse crackles) to screen for evidence of pneumonia. A chest X-ray should not delay the emergency management of DKA.
See our CXR interpretation guide for more details.
Interventions
Oxygen
Administer oxygen to all critically unwell patients during your initial assessment. This typically involves the use of a non-rebreathe mask with an oxygen flow rate of 15L. If the patient has COPD and a history of CO2 retention you should switch to a venturi mask as soon as possible and titrate oxygen appropriately.
If the patient is conscious, sit them upright as this can also help with oxygenation.
Antibiotics
If an infection is suspected, IV antibiotics should be administered as soon as possible.
Antibiotics should be prescribed in keeping with local guidelines.
CPR
If the patient loses consciousness and there are no signs of life on assessment, put out a crash call and commence CPR.
Re-assessment
Make sure to re-assess the patient after any intervention.
Circulation
Clinical assessment
Pulse and blood pressure
Assess the patient’s pulse and blood pressure:
- Tachycardia is common in the context of DKA due to hypovolaemia and catecholamine release.
- Bradycardia is a late sign and often precedes cardiac arrest.
- Hypovolaemia is common in the context of DKA due to reduced oral intake and vomiting.
Inspection
Inspect the patient from the end of the bed: they may appear drowsy, confused and/or clammy/pale.
Capillary refill time
Capillary refill time may be prolonged if the patient is hypovolaemic.
Fluid balance assessment
Calculate the patient’s fluid balance:
- Calculate the patient’s current fluid balance using their fluid balance chart (e.g. oral fluids, intravenous fluids, urine output, drain output, stool output, vomiting) to inform resuscitation efforts.
- Reduced urine output (oliguria) is typically defined as less than 0.5ml/kg/hour in an adult.
Investigations and procedures
Intravenous cannulation
Insert at least one wide-bore intravenous cannula (14G or 16G) and take blood tests as discussed below.
See our intravenous cannulation guide for more details.
Blood tests
Collect blood tests after cannulating the patient including:
- FBC: to screen for anaemia and signs of infection.
- U&Es: to assess renal function and electrolyte levels (e.g. hyperkalaemia).
- CRP: to screen for evidence of infection.
- Serum glucose: to accurately measure the patient’s current serum glucose levels (point of care devices are often inaccurate in the context of very high glucose levels).
- Liver function tests: to screen for liver abnormalities.
Record an ECG
An ECG should be performed to screen for cardiac pathology such as arrhythmias which may be precipitated by electrolyte abnormalities (e.g. tall tented T waves in hyperkalaemia). Performing an ECG should not delay the emergency management of DKA.
Interventions
Fluid resuscitation
Patients with DKA require fluid resuscitation to restore circulatory volume, clear ketones, correct electrolyte abnormalities and increase renal perfusion. The choice of fluid type, rate of administration and volume should be tailored to the individual patient based upon their vital signs and electrolytes. Refer to your local guidelines which should provide a clear protocol for the management of DKA.
See our fluid prescribing guide for more details on resuscitation fluids.
CPR
If the patient loses consciousness and there are no signs of life on assessment, put out a crash call and commence CPR.
Re-assessment
Make sure to re-assess the patient after any intervention.
Disability
Clinical assessment
Consciousness
In the context of DKA, a patient’s consciousness level may be reduced.
Assess the patient’s level of consciousness using the AVPU scale:
- Alert: the patient is fully alert, although not necessarily orientated.
- Verbal: the patient makes some kind of response when you talk to them (e.g. words, grunt).
- Pain: the patient responds to a painful stimulus (e.g. supraorbital pressure).
- Unresponsive: the patient does not show evidence of any eye, voice or motor responses to pain.
If a more detailed assessment of the patient’s level of consciousness is required, use the Glasgow Coma Scale (GCS).
Pupils
Assess the patient’s pupils:
- Inspect the size and symmetry of the patient’s pupils
- Assess direct and consensual pupillary responses
Drug chart review
Review the patient’s drug chart for medications which may cause a reduced level of consciousness (e.g. opioids, sedatives, anxiolytics, insulin, oral hypoglycaemic medications).
Investigations and procedures
Blood glucose and ketones
Measure the patient’s capillary blood glucose and ketone levels to confirm the diagnosis and guide the management of DKA.
A blood glucose level may already be available from earlier investigations (e.g. ABG, venepuncture).
The normal reference range for fasting plasma glucose is 4.0 – 5.8 mmol/l.
See our blood glucose measurement guide for more details.
Interventions
Insulin therapy
A fixed-rate intravenous insulin infusion should be commenced initially to suppress ketogenesis, reduce blood glucose levels and address electrolyte disturbances. Refer to your local guidelines for further details.
Glucose infusion
After initial insulin therapy has reduced plasma blood glucose levels (e.g. to below 12 mmol/L) an infusion containing normal saline and 5% dextrose is typically commenced to prevent the development of hypoglycaemia, whilst allowing insulin therapy to continue to suppress ketogenesis and reduce serum electrolyte concentrations. Refer to your local guidelines for further details.
Potassium infusion
In some cases, normal saline with additional potassium is required to prevent overcorrection of serum potassium levels which would otherwise result in hypokalaemia. The addition of a fluid infusion containing some potassium allows insulin therapy to continue to suppress ketogenesis and normalise plasma pH whilst preventing the development of hypokalaemia. Typically potassium levels should be maintained between 4.0 – 5.5 mmol/L and close monitoring is required.
Maintain the airway
Alert a senior immediately if you have any concerns about the consciousness level of a patient. A GCS of 8 or below warrants urgent expert help from an anaesthetist. In the meantime, you should re-assess and maintain the patient’s airway.
CPR
If the patient loses consciousness and there are no signs of life on assessment, put out a crash call and commence CPR.
Re-assessment
Make sure to re-assess the patient after any intervention.
Exposure
It may be necessary to expose the patient during your assessment: remember to prioritise patient dignity and conservation of body heat.
Clinical assessment
Inspection
Inspect for evidence of self-injection sites (e.g. areas of lipohypertrophy) if it is unclear if the patient is diabetic.
Inspect the urine currently in the catheter bag and note its appearance (e.g. cloudy urine may indicate urinary tract infection).
Inspect for evidence of infection on the skin (e.g. cellulitis).
Temperature
Measure the patient’s temperature:
- If fever is present, make sure to consider co-existing infection.
- Hypothermia may be present if the patient has been unconscious and exposed for some time.
Investigations and procedures
Urinalysis and culture
Perform urinalysis and send the urine for culture if urinary tract infection is suspected. Urinary tract infections are a common DKA precipitant.
Interventions
Antibiotics
If an infection is suspected, IV antibiotics should be administered as soon as possible.
Antibiotics should be prescribed in keeping with local guidelines.
Catheterisation
Catheterise the patient to closely monitor urine output to guide fluid resuscitation and need for escalation.
Reverse hypothermia
Use blankets to re-warm patients who are mild to moderately hypothermic.
Consider active re-warming techniques in patients with severe hypothermia.
CPR
If the patient loses consciousness and there are no signs of life on assessment, put out a crash call and commence CPR.
Re-assessment
Make sure to re-assess the patient after any intervention.
Reassess ABCDE
Re-assess the patient using the ABCDE approach to identify any changes in their clinical condition and assess the effectiveness of your previous interventions.
Deterioration should be recognised quickly and acted upon immediately.
Seek senior help if the patient shows no signs of improvement or if you have any concerns.
Support
You should have another member of the clinical team aiding you in your ABCDE assessment, such a nurse, who can perform observations, take samples to the lab and catheterise if appropriate.
You may need further help or advice from a senior staff member and you should not delay seeking help if you have concerns about your patient.
Use an effective SBARR handover to communicate the key information effectively to other medical staff.
Next steps
Well done, you’ve now stabilised the patient and they’re doing much better. There are just a few more things to do…
Take a history
Revisit history taking to explore relevant medical history and identify any precipitating factors for DKA. If the patient is confused you might be able to get a collateral history from staff or family members as appropriate.
See our history taking guides for more details.
Review
Review the patient’s notes, charts and recent investigation results.
Review the patient’s current medications and check any regular medications are prescribed appropriately.
Document
Clearly document your ABCDE assessment, including history, examination, observations, investigations, interventions, and the patient’s response.
See our documentation guides for more details.
Discuss
Discuss the patient’s current clinical condition with a senior clinician using an SBARR style handover. Consider any precipitating factors for the development of DKA and involve the diabetes team in the patient’s care.
Questions which may need to be considered include:
- Are any further assessments or interventions required?
- Does the patient need a referral to HDU/ICU?
- Does the patient need reviewing by a specialist?
- Should any changes be made to the current management of their underlying condition(s)?
Handover
The next team of doctors on shift should be made aware of any patient in their department who has recently deteriorated.
References
- Diabetes UK with the Joint British Diabetes Societies Inpatient Care Group. Management of diabetic ketoacidosis in adults. Available from: [LINK].
- NICE guidelines. Diabetes (type 1 and type 2) in children and young people: diagnosis and management. Published August 2015. Available from: [LINK].
