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Diabetic Ketoacidosis (DKA) - EMT Student Reference

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1. Definition

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2. Pathophysiology (Simplified)

No insulin → cells can't use glucose
        ↓
Body thinks it's "starving"
        ↓
Fat breakdown (lipolysis) → free fatty acids → KETONES (β-hydroxybutyrate, acetoacetate, acetone)
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Ketones are acidic → blood pH drops (ACIDOSIS)
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High blood glucose → osmotic diuresis → massive fluid + electrolyte loss (Na, K, Mg, Phosphate)
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Dehydration, electrolyte imbalances
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Body tries to blow off CO₂ to compensate → KUSSMAUL RESPIRATIONS

• Rosen's Emergency Medicine, p. 2542: "DKA is a syndrome in which insulin deficiency and glucagon excess combine to produce a hyperglycemic, dehydrated, acidotic patient with profound electrolyte imbalances."

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3. Causes / Precipitating Factors

• Goldman-Cecil Medicine, Table 210-11

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4. Signs & Symptoms

History (Subjective - what the patient tells you)

• Polydipsia - excessive thirst
• Polyuria - frequent urination
• Polyphagia - increased hunger (early), then anorexia
• Nausea and vomiting
• Abdominal pain - present in ~50% of patients, especially children; may mimic acute abdomen
• Weakness, lethargy, fatigue
• Visual blurring
• Weight loss

Physical Exam (Objective - what you assess)

Key point for EMTs: The combination of Kussmaul respirations + fruity breath + tachycardia + altered mental status in a known or suspected diabetic = DKA until proven otherwise.

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5. Diagnostic Criteria

• Rosen's Emergency Medicine, Table 115.4

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6. Prehospital Clinical Assessment (EMT Approach)

Scene Size-Up

• Look for medical alert tags (diabetic ID)
• Check for insulin/glucagon at the scene
• Note any infection signs (fever, wounds)

Primary Assessment (ABCs)

• Airway: Protect if altered mental status or vomiting
• Breathing: Note Kussmaul respirations (deep, rapid, labored) - do NOT try to slow breathing down; this is compensatory
• Circulation: Check for tachycardia, hypotension, skin turgor, capillary refill

Secondary Assessment

• Mental status (AVPU / GCS)
• Blood glucose: Most EMT scopes include glucometry - expect >250 mg/dL, often much higher
• Skin assessment: Dry, flushed, warm skin
• Breath odor: Fruity/sweet (acetone)
• Vital signs: HR, RR, BP, temperature
• 12-lead ECG if available - hyperkalemia (initially) can cause peaked T-waves and cardiac arrhythmias; underlying MI may be the trigger

SAMPLE History

• Signs/symptoms: polydipsia, polyuria, nausea, vomiting, abd pain
• Allergies: including to insulin
• Medications: insulin type and dose, SGLT-2 inhibitors, steroids
• Past history: diabetes (Type 1 vs. 2), prior DKA
• Last meal and last insulin dose
• Events: recent illness, infection, stress, trauma

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7. Prehospital Management

Step-by-Step Prehospital Treatment

• Position the patient for airway protection (recovery position if unconscious/vomiting)
• Apply supplemental oxygen if SpO₂ <94% or signs of respiratory distress
• Be prepared to suction (nausea/vomiting is common)
• Do NOT suppress Kussmaul respirations - this is the body compensating

• Isotonic IV fluids are the single most important prehospital treatment
• Target: Normal saline (0.9% NS) or Lactated Ringer's
• Initial bolus: ~20 mL/kg (~1-1.5 L in adults), then ~500 mL/hr
• Fluids help: reduce glucose, improve perfusion, correct electrolyte shifts

• Check and document blood glucose
• If glucose is >250 mg/dL with signs of DKA, begin resuscitation
• Do NOT give dextrose (D50) - this worsens hyperglycemia

• Hyperkalemia and electrolyte imbalances risk life-threatening arrhythmias
• Look for peaked T-waves, wide QRS complexes

• Continuously reassess mental status, breathing, vitals
• Rapid transport to the ED - definitive care requires insulin drip, electrolyte replacement, and IV fluids
• Call ahead: alert the ED to a suspected DKA patient so the team can prepare

What NOT to Do in the Field

• Do NOT give insulin without ALS protocols (risk of hypoglycemia, hypokalemia, cerebral edema)
• Do NOT give sodium bicarbonate routinely (can worsen outcomes, associated with cerebral edema in children)
• Do NOT slow down the patient's Kussmaul breathing

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8. Pediatric Considerations

• Abdominal pain is almost always idiopathic (not a sign of intra-abdominal disease) and resolves with treatment
• Cerebral edema is a rare but deadly complication (up to 1% of severe pediatric DKA, ~50% mortality)
  • Watch for: headache, pupil changes, sudden AMS worsening, bradycardia (Cushing's triad)
  • Risk is associated with severity of acidosis and overly rapid fluid administration
• Sodium bicarbonate is contraindicated - strongly linked to cerebral edema in children

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9. Quick Summary Table for Field Use

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• Rosen's Emergency Medicine: Concepts and Clinical Practice, 9th ed., Chapter 115
• Goldman-Cecil Medicine, International Edition, Chapter 210
• JEMS: "Assessment & Treatment of Five Diabetic Emergencies"