Diabetic Ketoacidosis (DKA)

The blood sugar is NOT the emergency- Acidosis, Hypokalemia, and Dehydration are!!!

Signs and Symptoms

  • Vomiting
  • Abdominal pain
  • Polydipsia
  • Polyuria


  • Diabetes
    • Blood sugar
      • Typically notably elevated (>250 mg/dL)
      • Can be normal in certain circumstances
  • Ketones
    • Easiest test is a urinalysis
    • Serum ketones also can be obtained
  • Acidosis
    • Blood gas (arterial or venous)
      • pH <7.3

Step 2: Check Potassium Level

  • Patients frequently depleted of whole body potassium
  • Insulin administration will causes further drops in serum potassium level

Step 3: Replace Potassium

  • If potassium <3.3, do not give insulin
    • Replace potassium prior to insulin
  • If potassium >3.3 but <5.5
    • Consider supplementing potassium at this point
    • May continue insulin

Step 4: Give Fluids

  • Adult patients are frequently 3-6 LITERS depleted
  • 20 ml/kg NS during first hour

Step 5: Start an Insulin Drip

  • This accomplishes 2 things…
    • It decreases blood sugar
    • It also decreases acid production

Additional Reading


  1. Otari Beldishevski-Shotadze

    Hey Zack, thanks for the podcast. I just have a question about the adjusted Na and K levels and whether they should be considered in the management process. I have heard in the past that if the low Na on blood gas isn’t rising as you manage the glycemia than there is a risk of cerebral edema. Could you please expand on this further. Thank you.

  2. ER nurse

    Thank you for this
    Er nurse checking in, these podcasts help me understand the basics and what to look out for when managing care for these patients. Many times the ER doctor may have 13 other patients and we can be the first to alert them when labs result and provide them updates.
    I love listening to you challenge the other med student with your cases as well. I really like the way you explain things. Thanks for your hard work on these podcasts they make for great listening for lots of people.

    • Zack

      Appreciate the comment and thank you for all that you do as an ER nurse!!!

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