Diabetic Ketoacidosis (DKA) — History and Physical — Clinical Pathway: Emergency Department, ICU and Inpatient

Diabetic Ketoacidosis (DKA) Clinical Pathway — Emergency Department, ICU and Inpatient

History and Physical Exam

History
  • New Diagnosis
    • Polyphagia, polydipsia, polyuria
    • Weight loss, anorexia, vomiting
    • Fatigue, malaise
  • Known Diagnosis
    • Insulin use, most recent dose, insulin pump
    • Home glucose levels, urine ketones
    • Type DM and age at diagnosis
    • Previous hospitalizations, episodes of DKA
  • Hydration Status
    • PO Intake
    • Nausea, vomiting
  • Causes
    • Poor metabolic control
    • Acute illness, trauma
    • Per-pubertal growth
    • Medications
    • Ingestion, drugs, ETOH
Physical Exam
  • Circulatory
    • VS, MS
    • Signs of intravascular volume depletion, shock
    • Tachycardia, poor perfusion
    • Hyperosmolar state preserves intravascular volume, so true volume loss is underestimated
  • Neuro
  • Respiratory
    • Tachypnea
    • Kussmaul respiration
  • GI
    • Abdominal tenderness

Cerebral Edema

  • Leading cause of morbidity and mortality in DKA
  • Etiology unclear, attributed to fluids shifts in the setting of cellular osmolar imbalance resulting in cerebral hypoperfusion and prolonged acidosis with ischemia
  • Typically occurs 4-12 hrs after treatment is initiated
  • May be present before treatment or occur as late as 24-48 hrs after treatment initiated
Risk Factors for Cerebral Edema
  • Age < 3 yrs
  • Prior history of DKA
  • pH < 7.0
  • Failure of corrected Na to fall to normal range during treatment
  • Administration of bicarbonate therapy
  • Elevated BUN (27 + 14 mg/dL) at presentation
  • Low PaCO2 levels (11.3 ± 6.5 mm Hg) at presentation
  • Administration of insulin (bolus or infusion) in first hour of fluid treatment
  • Initial glucose > 1,000 mg/dL
Treatment
  • Elevate head of bed
  • IV mannitol 0.35-1 g/kg over 20 min, may repeat in 2 hrs
  • IV 3% saline 5-10 mL/kg over 30 min
  • Head CT, Neurosurgery Consult