Emergency Department Clinical Pathway for Evaluation/Treatment
of Children with Suspected Diabetic Ketoacidosis (DKA)

Child with Suspected DKA
DKA: Definition & Treatment Goals
60 Minutes
Initial FLOC/RN Team Assessment
  • ABC, VS, level of dehydration
  • Mental status, neuro exam, GCS
  • Risk for cerebral edema
  • CR monitor, VS q 15 min, I/O q 1 hr
  • Start DKA Flow Sheet
IV Access
  • 2 PIV (fluid resuscitation, blood draws)
Initial Labs
  • POC glucose, POC BOHB
  • VBG, BMP, Ca, Mg, PO4, Hb A1C
  • HCG, CBC as needed
IV Fluids
  • NS, 20 mL/kg over 1 hour
Diagnosis DKA by PE, History, Labs
Ongoing Treatment
  • Begin 1.5 times maintenance with NS until
    2 bag system ready
  • Continue 1.5 with 2 bag system
  • Initial results
  • Order K replacement based on BMP results
  • Perform ECG if K < 2.5
  • Order regular insulin at 0.1 units/kg/hr as soon as possible
  • Start insulin infusion 1 hour AFTER fluid resuscitation begins
  • Stop insulin pump during DKA treatment
  • Decrease glucose 50-100 mg/dL per hour
  • Order 2 bag system, D0 and D10 with electrolytes
  • Begin dextrose when the child’s glucose is < 300 mg/dL or decrease in POC glucose > 100 mg/dL per hour
  • VS, neuro assess q 15 minutes until stable
Posted: June 2006
Last Revised: January 2024
Authors: V. Srinivasan, MD; K. Lord, MD; C. Jacobstein, MD; S. Gaines, RN; J. Lavelle, MD; A. Ackerman, MD;
M. Vajravelu, MD; T. Kaushal, MD; T. Flowers, RN