DKA – Diabetic Ketoacidosis 💉
Emergency management of diabetic ketoacidosis (DKA). Diagnosis, fluid resuscitation, insulin protocol, electrolyte management, and monitoring for NCHDs.
🧠 Definition & Criteria
- Glucose >13.8 mmol/L + ketones >3 mmol/L (or ++ on dipstick)
- pH <7.3 or HCO₃⁻ <18 mmol/L, anion gap >10
- ⚠️ Refer to local guidelines for specific management protocols ⚠️
📞 What to Ask / Orders to Make
- Capillary glucose + blood ketones
- Venous/arterial blood gas (pH, HCO₃⁻, lactate)
- U&E, FBC, CRP; submit septic screen if unwell
- Insert 2 × IVs, urinary catheter, consider CVP
- Call senior/endocrine early — ICU if severe
🧾 Initial Assessment
- ABCs — airway, breathing, circulation
- Vitals + GCS; assess hydration (CRT, turgor)
- Look for infection, MI, pancreatitis as triggers
💧 Fluid Resuscitation
- 0.9% NaCl: 1 L/hr ×1 hr → 1 L/2 hr → 1 L/4 hr → 1 L/8 hr
- Switch to 5% dextrose once glucose <12 mmol/L
- Avoid rapid glucose drop — target reduction of 3–5 mmol/L/hr
⚡ Potassium Replacement
- Do not add K⁺ until urine output confirmed
- >5.0: none; 3.5–5.0: +20 mmol/L; <3.5: +40 mmol/L
- Monitor serum K⁺ every 2–4 hrs; ECG if deranged
💉 Insulin Infusion
- Start 0.1 U/kg/hr regular insulin IV after fluids started
- Titrate per glucose: 0–4: 0, 4–10: 0.5 U/hr, … >20: call senior
- Add dextrose when glucose <12 mmol/L; don’t stop insulin
🧪 Ongoing Monitoring
- Hourly glucose + ketones
- VBG q2–4 hrs, U&E, K⁺ with matching frequency
- Watch for cerebral oedema: headache, ↓GCS, bradycardia
🔍 Investigations
- ABG/VBG, U&E, FBC, CRP
- Blood & urine cultures if suspect infection
- CXR/ECG if respiratory/MI signs or sepsis
📌 Escalation
- ICU if pH <6.9, hypotensive, ↓GCS, K⁺ deranged
- Overlap SC insulin with IV infusion (~30 min) once eating
- Identify and treat underlying cause (infection, omission)
- Endocrine/ICU referral early
Note Template
Ready-to-use clinical note structure
🕒 26 / 05 / 2026 — 12:26 ATRP re: diabetic ketoacidosis (DKA) Patient: [age] [sex] Admission Dx: [reason for admission] PMHx: [type 1 diabetes, insulin compliance] 🧾 Hx: • Symptoms: polyuria, polydipsia, vomiting, abdominal pain • Duration and precipitating factors (infection, insulin omission) • Previous DKA episodes 🩺 Exam: • Vitals: HR __ BP __ RR __ Temp __ SpO₂ __ • Signs of dehydration, Kussmaul breathing • Mental status and GCS 📋 Impression: DKA with metabolic acidosis and ketosis 📌 Plan: • ABCDE assessment and oxygen as needed • IV fluids: 0.9% saline bolus then maintenance • IV insulin infusion • Monitor blood glucose, ketones, electrolytes hourly • Correct electrolytes, especially potassium • Identify and treat precipitating cause • Frequent clinical and biochemical monitoring 👤 [Your Name], [Role] IMC: _______