🚨 Diabetic Ketoacidosis
Overview
Diabetic Ketoacidosis (DKA) is a life-threatening complication of diabetes, characterised by hyperglycaemia, ketosis, and metabolic acidosis. It primarily affects individuals with type 1 diabetes but can occur in type 2. Prompt diagnosis and aggressive management are essential to prevent severe morbidity and mortality.
Recognition
Patients typically present with polyuria, polydipsia, weight loss, nausea, vomiting, and abdominal pain. Kussmaul breathing (deep, rapid respirations) and a 'pear drop' breath odour (due to ketones) are classic signs. Altered mental status, ranging from lethargy to coma, indicates severe disease.
Initial Assessment (ABCDE)
A: Assess airway patency; protect if GCS is low. B: Assess breathing for rate, depth (Kussmaul), and oxygen saturation. C: Assess circulation for heart rate, blood pressure, capillary refill, and signs of dehydration/shock. D: Assess disability using GCS, and check blood glucose. E: Expose fully to check for signs of infection, skin turgor, and temperature.
Red Flags
Persistent or worsening acidosis despite treatment, rapidly decreasing GCS, signs of cerebral oedema (headache, bradycardia, hypertension, neurological deterioration), and refractory hypotension are critical red flags. Electrolyte imbalances, particularly hypokalaemia, during treatment are also concerning.
Investigations
Bedside: Capillary blood glucose, urine dipstick (for ketones), blood ketone levels (beta-hydroxybutyrate), ECG. Bloods: Arterial or venous blood gas (for pH, bicarbonate, pCO2), urea and electrolytes, creatinine, full blood count, blood cultures if infection suspected. Imaging: Chest X-ray if respiratory symptoms, CT head if cerebral oedema suspected.
Immediate Management
Administer high-flow oxygen if hypoxic. Establish intravenous access and commence aggressive intravenous fluid resuscitation with isotonic saline. Start a fixed-rate intravenous insulin infusion to correct hyperglycaemia and suppress ketogenesis. Monitor and replace potassium as needed. Identify and treat any precipitating factors, such as infection.
Escalation Triggers
Any patient presenting with DKA requires immediate senior medical review. Deterioration in GCS, signs of cerebral oedema, refractory shock, or severe electrolyte abnormalities warrant urgent critical care involvement. Failure to improve despite initial management also requires escalation.
MLA High-Yield Notes
DKA is a medical emergency. The key diagnostic triad is hyperglycaemia (>11 mmol/L), ketosis (blood ketones >3 mmol/L or urine ketones ++), and acidosis (pH <7.3 or bicarbonate <15 mmol/L). Cerebral oedema is a rare but devastating complication, especially in children. Potassium replacement is crucial during insulin therapy.
References
- Joint British Diabetes Societies (JBDS) for Inpatient Care: Management of Diabetic Ketoacidosis in Adults
- NICE Guideline NG18: Diabetes (type 1 and type 2) in children and young people: diagnosis and management
- Resuscitation Council UK: Advanced Life Support Guidelines