definition, signs & symptoms, causes, clinical assessment and management of DKA for EMT students take reference from the above article.
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Diabetic Ketoacidosis (DKA) - EMT Study Guide
Based on the ADA Standards of Care in Diabetes 2024 (InSIGHT Guidelines article) and supported by ROSEN's Emergency Medicine & Goldman-Cecil Medicine
1. Definition
Diabetic Ketoacidosis (DKA) is a life-threatening acute complication of diabetes caused by a severe lack of insulin. This leads to three simultaneous metabolic crises:
| Feature | What it means |
|---|---|
| Hyperglycemia | Blood glucose ≥200 mg/dL (11.1 mmol/L) |
| Ketosis | β-Hydroxybutyrate ≥3.0 mmol/L OR urine ketones 2+ or greater |
| Metabolic acidosis | Blood pH <7.3 AND/OR bicarbonate <18 mmol/L |
DKA occurs primarily in Type 1 diabetes but can also occur in Type 2 diabetes under certain stress conditions. It is a true emergency - early recognition and treatment are critical.
2. Pathophysiology (The "Why")
Understanding the mechanism helps EMTs recognize and anticipate complications.
The core problem: Without insulin, cells cannot absorb glucose. The body responds as if it is starving, even though glucose is plentiful in the blood.
Chain of events:
- Insulin deficiency (absolute in Type 1, or relative from a trigger in Type 2)
- Counter-regulatory hormones (glucagon, cortisol, epinephrine) surge
- Liver dumps more glucose into the blood → hyperglycemia
- Fat cells break down (lipolysis) → free fatty acids flood to the liver → converted to ketone bodies (β-hydroxybutyrate, acetoacetate, acetone)
- Ketones acidify the blood → metabolic acidosis
- High blood glucose overwhelms the kidneys → glucose spills into urine → osmotic diuresis
- Osmotic diuresis causes massive loss of water, sodium, potassium, magnesium, and phosphorus → severe dehydration and electrolyte imbalances
In severe DKA, patients can lose 70-120 mL of water per kg of body weight, with large deficits of potassium (5-7 mEq/kg), sodium (8-10 mEq/kg), and phosphorus. (ROSEN's Emergency Medicine)
3. Causes / Precipitating Factors
(ADA article + Goldman-Cecil Medicine)
Most Common Triggers:
- Infection (most frequent - UTI, pneumonia, sepsis)
- Insulin omission - patient missed doses or stopped insulin (non-adherence)
- New-onset Type 1 diabetes - DKA may be the first presentation
- Acute coronary syndrome (heart attack as a stressor)
- Unknown cause
Other Triggers:
- Trauma, surgery
- Cerebrovascular accident (stroke)
- Acute pancreatitis
- Alcohol intoxication / substance use (cocaine)
- Drugs: corticosteroids, SGLT-2 inhibitors (euglycemic DKA - glucose may be normal!), antipsychotics (clozapine, olanzapine), thiazide diuretics, sympathomimetics
- Endocrine disorders: Cushing syndrome, thyrotoxicosis
- Severe burns, hyperthermia, hypothermia
EMT Pearl: Always ask about recent illness, missed insulin, or new medications. SGLT-2 inhibitors (empagliflozin, dapagliflozin) can cause DKA with near-normal blood sugar - do not rule out DKA based on glucose alone.
4. Signs & Symptoms
(ADA article + ROSEN's Emergency Medicine)
Classic Symptoms (develop over hours to days):
| Symptom | Mechanism |
|---|---|
| Polyuria (excessive urination) | Osmotic diuresis from hyperglycemia |
| Polydipsia (excessive thirst) | Dehydration from osmotic diuresis |
| Weight loss | Fluid loss + breakdown of fat and muscle |
| Fatigue/weakness | Cells starved of glucose; electrolyte depletion |
| Kussmaul breathing | Deep, rapid, labored breaths - the body exhaling CO2 to compensate for acidosis |
| Vomiting | Acidosis + gastroparesis |
| Abdominal pain | Ketosis, dehydration, or underlying trigger (pancreatitis) |
| Altered mental status | Hyperosmolarity + dehydration affecting the brain |
Physical Exam Findings (What the EMT sees):
- Fruity/acetone breath - from acetone (a ketone) being exhaled
- Dry mucous membranes, sunken eyes, poor skin turgor - dehydration
- Tachycardia - compensating for low circulating volume
- Hypotension - in severe dehydration/shock
- Warm, flushed, dry skin
- Kussmaul respirations - deep, rapid, labored (often mistaken for respiratory distress)
- Decreased level of consciousness - from mild confusion to coma
- Abdominal tenderness - may mimic an acute abdomen
The mental status change is driven by hyperosmolarity and dehydration - the more severe the dehydration and glucose elevation, the more altered the patient. (ROSEN's Emergency Medicine)
5. Clinical Assessment
Diagnostic Criteria (ADA 2024 Standards):
A patient must meet all three criteria:
| Criterion | Threshold |
|---|---|
| Diabetes / Hyperglycemia | Glucose ≥200 mg/dL OR prior history of diabetes |
| Ketosis | β-Hydroxybutyrate ≥3.0 mmol/L OR urine ketones 2+ |
| Metabolic acidosis | pH <7.3 AND/OR bicarbonate <18 mmol/L |
Prehospital Assessment Approach for EMTs:
Scene Size-Up: Look for insulin, glucose meters, diabetic ID bracelets.
Primary Survey:
- Airway - protect if AMS is present
- Breathing - note Kussmaul pattern (deep, labored, rapid)
- Circulation - check for tachycardia, hypotension, signs of shock
SAMPLE History:
- Symptoms: When did symptoms start? Polyuria, thirst, vomiting?
- Allergies
- Medications: What insulin are they on? Did they take it? SGLT-2 inhibitors?
- Past history: Known diabetic? Type 1 or 2?
- Last oral intake: When did they last eat?
- Events: Any illness, infection, missed doses, emotional stress?
Vital Signs: Tachycardia, possible hypotension, tachypnea (Kussmaul), temperature (fever suggests infection as trigger).
Blood Glucose Check: A BGL ≥250 mg/dL in a sick, vomiting patient with altered breathing and history of diabetes should raise strong suspicion for DKA.
Differentiate DKA from Hypoglycemia (critical):
| Feature | DKA | Hypoglycemia |
|---|---|---|
| Onset | Gradual (hours-days) | Sudden (minutes) |
| Breath | Fruity/acetone | Normal |
| Breathing | Kussmaul (deep, rapid) | Normal |
| Skin | Warm, dry, flushed | Pale, cold, diaphoretic |
| Blood glucose | HIGH (>250) | LOW (<70) |
| Response to glucose | None | Immediate improvement |
6. Management
Management Goals (ADA 2024):
- Restore circulatory volume and tissue/organ perfusion
- Resolve ketoacidosis
- Correct electrolyte imbalances, particularly potassium
A. Fluid Replacement (First Priority)
- 0.9% Normal Saline (NaCl) or other crystalloid for severe hypovolemia
- Initial rate: 1 L/hour (or at a clinically appropriate rate)
- Goal: Replace 50% of estimated fluid deficit in the first 8-12 hours
- Once blood glucose drops to <250 mg/dL, add dextrose to IV fluids to prevent hypoglycemia while insulin continues
EMT Role: Establish IV access and begin 0.9% NS fluid resuscitation en route. Do NOT delay transport.
B. Insulin Therapy
- IV Regular Insulin: 0.1 units/kg IV bolus, then continuous IV infusion at 0.1 units/kg/hour
- Continue the drip until:
- Plasma ketones <0.6 mmol/L, AND
- Venous pH ≥7.3 OR bicarbonate ≥18 mmol/L, AND
- Patient can tolerate oral intake
- Transition to subcutaneous insulin 1-2 hours before stopping the IV drip to prevent rebound hyperglycemia
EMT Role: Insulin infusions are typically a hospital/ALS intervention. EMTs should not give insulin in the field for DKA. Focus on fluids and transport.
C. Potassium Management (Critical!)
- DKA patients have a large total body potassium deficit even if serum K+ appears normal or high (acidosis shifts K+ out of cells temporarily)
- When insulin is given, potassium shifts back INTO cells and serum K+ can drop dangerously
- Replace potassium as long as serum K+ <5.0 mmol/L
- Monitor potassium continuously during treatment
Why it matters for EMTs: Hypokalemia can cause life-threatening cardiac arrhythmias. Report any cardiac rhythm changes.
D. Bicarbonate Therapy
- Generally NOT recommended in routine DKA management
- Only considered if pH <7.0 (extreme acidosis)
- Routine bicarbonate use can cause paradoxical worsening and hypokalemia
E. Prehospital EMT Priorities Summary:
| Priority | Action |
|---|---|
| 1. Recognize DKA | High glucose + ketotic breath + Kussmaul breathing + vomiting + dehydration |
| 2. Airway | Position, suction if vomiting; consider BVM if apneic |
| 3. IV Access | Large-bore IV; begin 0.9% NS fluid bolus |
| 4. Monitor | Vitals, ECG (watch for arrhythmias from K+ imbalance), glucose |
| 5. Transport | Rapid transport to emergency department - DO NOT delay |
| 6. Report | Notify receiving hospital early with suspected DKA |
| 7. Do NOT give insulin | Insulin without K+ monitoring is dangerous in prehospital setting |
7. Prevention & Patient Education
(ADA 2024 - InSIGHT Article)
EMTs treating repeat DKA patients can reinforce key education points:
- Daily blood glucose monitoring and ketone monitoring when ill
- Sick-day management - do NOT stop insulin during illness (increased need)
- Maintain hydration especially when sick
- Adjust insulin doses with guidance from their healthcare provider
- Early medical intervention - if DKA symptoms appear, seek care immediately
- Do not omit insulin - the most preventable cause of DKA
Quick Reference Memory Aid
"DKA = 3 Highs + 3 Missing Things"3 Highs: High glucose, High ketones, High acid (low pH)3 Missing Things: Missing insulin, Missing fluid, Missing potassium
Sources: ADA Standards of Care in Diabetes 2024 - InSIGHT Visual Guide (attached article); ROSEN's Emergency Medicine Concepts and Clinical Practice; Goldman-Cecil Medicine, International Edition. Recent review: Lowie BJ, Bond MC. Diabetic Ketoacidosis. Emerg Med Clin North Am. 2023 Nov [PMID: 37758416]
normal blood glucose level, normal keton level normal blood Ph? normal bicarbonate level?
Here are the normal values for all four parameters, with the DKA thresholds for comparison:
Normal Lab Values vs. DKA Thresholds
1. Blood Glucose
| Status | Value |
|---|---|
| Normal (fasting) | 70 – 99 mg/dL (3.9 – 5.5 mmol/L) |
| Normal (2hr post-meal) | <140 mg/dL (<7.8 mmol/L) |
| Pre-diabetes | 100 – 125 mg/dL |
| Diabetes diagnosis | ≥126 mg/dL (fasting) |
| DKA threshold | ≥200 mg/dL (≥11.1 mmol/L) |
2. Ketone Level (β-Hydroxybutyrate)
| Status | Value |
|---|---|
| Normal (blood) | <0.6 mmol/L |
| Mild ketosis | 0.6 – 1.5 mmol/L |
| Moderate ketosis | 1.5 – 3.0 mmol/L |
| DKA threshold | ≥3.0 mmol/L |
| Urine ketones (normal) | Negative or trace |
| DKA threshold (urine) | 2+ or greater |
3. Blood pH
| Status | Value |
|---|---|
| Normal arterial pH | 7.35 – 7.45 |
| Mild acidosis | 7.25 – 7.30 |
| Moderate acidosis | 7.10 – 7.24 |
| Severe acidosis (DKA) | <7.10 |
| DKA threshold | <7.30 |
| Bicarbonate therapy considered | <7.0 |
4. Bicarbonate (HCO₃⁻)
| Status | Value |
|---|---|
| Normal serum bicarbonate | 22 – 26 mmol/L |
| DKA threshold | <18 mmol/L |
| Severe DKA | <10 mmol/L |
Summary Cheat Sheet
| Parameter | Normal | DKA |
|---|---|---|
| Blood glucose | 70–99 mg/dL | ≥200 mg/dL |
| Blood ketones | <0.6 mmol/L | ≥3.0 mmol/L |
| Blood pH | 7.35–7.45 | <7.30 |
| Bicarbonate | 22–26 mmol/L | <18 mmol/L |
Memory tip for EMTs:
In DKA, glucose is too high, ketones are too high, pH is too low, and bicarbonate is too low - the body is overwhelmed and acidic.
Ketosis β-Hydroxybutyrate ≥3.0 mmol/L OR urine ketones 2+ explain
Great question. This is about two different ways to measure ketones - one in the blood, one in the urine. Either one can be used to confirm ketosis in DKA.
What Are Ketones?
When the body has no insulin, it cannot use glucose for fuel. So it breaks down fat instead. The liver converts fat into ketone bodies - three types:
| Ketone Body | Notes |
|---|---|
| β-Hydroxybutyrate (BHB) | The most abundant (75%) - measured in blood |
| Acetoacetate | Measured in urine dipstick |
| Acetone | Exhaled - causes the fruity/acetone breath |
Method 1: Blood Ketone - β-Hydroxybutyrate ≥3.0 mmol/L
What it is:
- A blood test (fingerstick or lab) that directly measures β-Hydroxybutyrate (BHB) - the main ketone produced in DKA
- Done with a point-of-care ketone meter (similar to a glucose meter)
Why it's preferred:
- More accurate and specific
- Detects ketosis earlier than urine testing
- Gives a precise number for monitoring treatment progress
- β-Hydroxybutyrate is the dominant ketone in DKA - directly reflects severity
Normal vs. DKA:
| Level | Interpretation |
|---|---|
| <0.6 mmol/L | Normal |
| 0.6 – 1.5 mmol/L | Mild ketosis |
| 1.5 – 3.0 mmol/L | Moderate (concerning) |
| ≥3.0 mmol/L | DKA confirmed |
| >6.0 mmol/L | Severe DKA |
Method 2: Urine Ketones "2+" (Dipstick Test)
What it is:
- A urine dipstick test that detects acetoacetate in the urine
- Results are reported as: Negative → Trace → 1+ → 2+ → 3+ → 4+
What "2+" means:
| Result | Meaning |
|---|---|
| Negative | No significant ketones |
| Trace / 1+ | Mild - may be from fasting, low-carb diet |
| 2+ | Significant ketosis - meets DKA threshold |
| 3+ / 4+ | Heavy ketosis - strongly suggests DKA |
Limitations of urine ketones:
- Less accurate than blood ketones
- Urine only detects acetoacetate, NOT β-Hydroxybutyrate (the main ketone in DKA)
- Can be falsely negative in early or severe DKA (when most ketones are BHB, not acetoacetate)
- Delayed - reflects ketones from hours earlier, not the current state
- Can remain positive even as the patient improves (urine clears slowly)
- Dehydrated patients may not produce enough urine to test
Why the Guideline Uses "OR"
The ADA uses "β-Hydroxybutyrate ≥3.0 mmol/L OR urine ketones 2+" because:
- Not every setting has a blood ketone meter - especially in the field, rural areas, or low-resource settings
- If blood testing is available → use blood BHB (more accurate)
- If only urine dipstick is available → use urine ketones (still clinically useful)
- Either result confirms the "K" in DKA
Simple Analogy for EMTs
Think of it like measuring a fever:
- Blood BHB = digital thermometer (precise, direct)
- Urine dipstick = forehead strip thermometer (less precise, but still useful when that's all you have)
Both confirm the problem. Blood is just more reliable.
EMT Takeaway
| Situation | Test to Use |
|---|---|
| Ketone meter available | Blood β-Hydroxybutyrate ≥3.0 mmol/L confirms DKA |
| Only urine dipstick available | Urine ketones 2+ or greater confirms DKA |
| Both available | Blood BHB is preferred and more reliable |
| Neither available | Rely on clinical signs + glucose + history |
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