Tiny Tips – Approach to Diabetic Ketoacidosis

In Medical Concepts, Tiny Tips by Larissa HattinLeave a Comment

Don’t Know Anything about Diabetic Ketoacidosis (DKA)? In Canada, 5 000 – 10 000 patients are admitted to the hospital with diabetic ketoacidosis (DKA) each year.1 Most of these patients will initially present to the Emergency Department.  The initial assessment and management of these patients in the ED is crucial, as 50% of DKA deaths occur in the first 48-72hrs.2  Managing DKA can be overwhelming for learners; interpreting blood gases, thinking about electrolyte and fluid replacement, managing blood glucose levels, and determining the underlying precipitant. Simply remembering ‘DKA’ will help to take you from Step One – assessment and symptoms – through to management.

Symptoms

  • Diuresis (polyuria), Dizziness, Dehydration, Delirium, Drinking (polydipsia)
  • Kussmaul respirations (deep, fast respirations that attempt to correct for metabolic acidosis)
  • Abdominal pain and vomiting

Diagnosis

  • Diabetic: capillary blood glucose >14mmol/L
  • Ketotic: beta-hydroxybutyrate >3mmol/L or ketonuria (3+)
  • Acidotic: pH <7.3 and HCO3– <15mmol/L

 

DKA Treatment Algorithm, Diabetic Ketoacidosis

DKA Treatment Algorithm.

Algorithm created using available resources.2–4

This article was copyedited by Michael Bravo (@bravbro).

References

1.
Chiasson J, Aris-Jilwan N, Bélanger R, et al. Diagnosis and treatment of diabetic ketoacidosis and the hyperglycemic hyperosmolar state. CMAJ. 2003;168(7):859-866. [PubMed]
2.
Cheng AYY. Introduction. Canadian Journal of Diabetes. 2013;37:S1-S3. doi: 10.1016/j.jcjd.2013.01.009
3.
Whitney W. DKA, “Answers.” DKA, “Answers.” https://emlyceum.com/2014/08/23/dka-answers/. Published August 23, 2014.
4.
Blouin D. Too much of a good thing: management of diabetic ketoacidosis in adults. Can Fam Physician. 2012;58(1):55-57. [PubMed]

Staff Review: Comments on DKA

This “DKA” pneumonic and algorithm are a great, simple way to keep the three key parts of diabetic ketoacidosis management straight. Remember that this is one of the most serious complications of diabetes seen in the emergency department as the mortality rate can range up to 10%. This clearly demonstrates the important role the emergency department physician plays in recognizing the condition and rapid treatment to improve outcomes in these patients.

A few pearls specific to the diagnosis and treatment of DKA:

Acidosis - A venous blood gas is adequate for the diagnosis and management of patients in DKA and can be used to determine a patient’s pH and HCO3-.

Urine ketones – While a simple and fast test, in early DKA the urinalysis may be negative for ketones, as Beta-hydroxybutyrate is not detected in the assay and may falsely impede making the correct diagnosis.

Potassium levels – The algorithm above covers potassium levels 3.3mmol/L. I would add that if the potassium level is >5.5mmol/L no potassium is needed to be added to supplement fluids administered.

Overall, DKA is a complex clinical process that rapidly changes throughout the patient’s stay in the Emergency Department. Patients in DKA require constant reassessment, repeat lab tests and close monitoring throughout their ED stay to ensure that the therapies started are correcting the underlying process and improving the patients clinical status.

Fareen Zaver
Fareen Zaver is an emergency physician at the University of Calgary. She is the lead editor and co-founder of the ALiEM AIR Pro series as well as co-author of the 2016 edition of must read EM.

Larissa Hattin

Larissa is a medical student at McMaster University.

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