Diabetic Ketoacidosis (DKA) | Acute Management |
ABCDE
geekymedics.com/diabetic-ketoacidosis-dka-emergency-management-abcde/
Dr Celestine Weegenaar August 15, 2018
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 foremergency 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:
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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 todelegate 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!
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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
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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 anasopharyngeal (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)
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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
A chest x-ray is not immediately indicated if all your examination findings are normal.
See our Chest x-ray interpretation guide here
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
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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 samplesduring 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 ECGhere and our guide to interpreting an ECGhere
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Intervention
Secure intravenous access
The gold standard is to insert 2 large bore cannulas for acutely unwell patients.
See our cannulation guide here
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.
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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’spotassium 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.
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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.
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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 anSBARR 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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