This guide provides an overview of the recognition and immediate management of diabetic ketoacidosis (DKA) using an ABCDE approach. The ABCDE approach can be used to perform a systematic assessment of a critically unwell patient. It involves working through the following steps:
Each stage of the ABCDE approach involves clinical assessment, investigations and interventions. Problems are addressed as they are identified and the patient is re-assessed regularly to monitor their response to treatment. This guide is designed to support students in preparing for emergency simulation sessions as part of their training, but should not be treated as a substitute for patient care.
DKA is characterised by:
DKA can be caused by either:
Typical symptoms of DKA include:
Typical clinical signs of DKA include:
General tips for applying an ABCDE approach in an emergency setting include:
When presented with an acute asthma scenario, there are important initial steps and interventions to consider. During a brief handover from a member of the nursing staff, it is important to take note of the patient's name, age, background and reason for requesting a review.
Introduce yourself to the patient, including your name and role. Ask how the patient is feeling, as this can provide insight into their current set of symptoms. Make sure the patient's notes, observation chart, and prescription chart are within reach. If possible, ask for another clinical staff member to assist you. Additionally, if the patient is unconscious or unresponsive, start Basic Life Support as per resuscitation guidelines.
If the patient can talk, their airway is patent and you can move on to the assessment of breathing. If not, look for signs of airway compromise, such as cyanosis, see-saw breathing, use of accessory muscles, diminished breath sounds, and added sounds. Open the mouth and inspect for anything obstructing the airway such as secretions or a foreign object.
Regardless of the underlying cause of airway obstruction, seek immediate expert support from an anaesthetist and the emergency medical team (often referred to as the ‘crash team’). In the meantime, you can perform some basic airway manoeuvres to help maintain the airway while awaiting senior input.
Open the patient's airway using a head-tilt chin-lift manoeuvre:
If the patient is suspected to have suffered significant trauma with potential spinal involvement, perform a jaw-thrust rather than a head-tilt chin-lift manoeuvre:
Any medications or fluids will need to be prescribed at the time (in some cases you may be able to delegate this to another member of staff). Your assessment and management should be documented clearly in the notes, however, this should not delay initial clinical assessment, investigations and interventions.
Check the patient's respiration rate:
Check the patient's oxygen saturation (SpO2):
To improve the patient's airway:
Airway adjuncts can enhance or be essential to maintain a patient's airway, and should be used while maintaining head-tilt chin-lift or jaw thrust. An oropharyngeal airway is a curved plastic tube used to relieve soft palate obstruction. It should only be inserted in unconscious patients.
To insert an oropharyngeal airway:
A nasopharyngeal airway is a soft plastic tube with one beveled end and one flanged end. Compared to oropharyngeal airways, NPAs are typically better tolerated in conscious or partly conscious patients. However, they should not be used in patients who may have sustained a skull fracture.
To insert a nasopharyngeal airway:
If the patient has signs of anaphylaxis (e.g. angioedema, rash), commence appropriate treatment.
If the patient loses consciousness with no signs of life, put out a crash call and commence CPR.
Remember to re-assess the patient after any intervention.
Auscultate the chest to screen for evidence of respiratory pathology (e.g. unilateral coarse crackles may indicate a pneumonia which may have been the precipitant for DKA).
An arterial blood gas (ABG) can provide useful information for management, including:
A chest X-ray may be indicated if abnormalities are noted on auscultation (e.g. reduced air entry, coarse crackles) to screen for pneumonia. Emergency management of DKA should not be delayed for a chest X-ray.
Oxygen should be administered to all critically unwell patients during the initial assessment. This typically involves the use of a non-rebreathe mask with an oxygen flow rate of 15L. If the patient has COPD and a history of CO2 retention, a venturi mask should be used as soon as possible and oxygen titrated appropriately.
If the patient is conscious, they should be seated upright to help with oxygenation.
If an infection is suspected, IV antibiotics should be administered as soon as possible.
Antibiotics should be prescribed in keeping with local guidelines.
If the patient loses consciousness and there are no signs of life on assessment, a crash call should be put out and CPR should be commenced.
Re-assess the patient after any intervention.
Assess the patient's pulse and blood pressure:
Inspect the patient from the end of the bed, as they may appear drowsy, confused, and/or clammy/pale.
Capillary refill time may be prolonged if the patient is hypovolaemic.
Calculate the patient's fluid balance:
Insert at least one wide-bore intravenous cannula (14G or 16G) and take blood tests as discussed below.
Collect blood tests after cannulating the patient including:
Diabetic Ketoacidosis (DKA) is typically diagnosed in patients with type 1 diabetes mellitus and is characterised by elevated levels of glucose and urinary ketones. To make a proper diagnosis, clinicians should take a variety of clinical assessments.
An ECG should be performed to screen for cardiac pathology such as arrhythmias which may be precipitated by electrolyte abnormalities (e.g. tall tented T waves in hyperkalaemia). Performing an ECG should not delay the emergency management of DKA.
Measure the patient's capillary blood glucose and ketone levels to confirm the diagnosis and guide the management of DKA. A blood glucose level may already be available from earlier investigations (e.g. ABG, venepuncture). The normal reference range for fasting plasma glucose is 4.0 – 5.8 mmol/l.
In the context of DKA, a patient's consciousness level may be reduced. Assess the patient's level of consciousness using the AVPU scale:
If a more detailed assessment of the patient's level of consciousness is required, use the Glasgow Coma Scale (GCS).
Assess the patient's pupils:
Review the patient's drug chart for medications which may cause a reduced level of consciousness (e.g. opioids, sedatives, anxiolytics, insulin, oral hypoglycaemic medications).
Patients with DKA require fluid resuscitation to restore circulatory volume, clear ketones, correct electrolyte abnormalities and increase renal perfusion. The choice of fluid type, rate of administration and volume should be tailored to the individual patient based upon their vital signs and electrolytes. Refer to your local guidelines which should provide a clear protocol for the management of DKA.
A fixed-rate intravenous insulin infusion should be commenced initially to suppress ketogenesis, reduce blood glucose levels and address electrolyte disturbances. Refer to your local guidelines for further details.
After initial insulin therapy has reduced plasma blood glucose levels (e.g.
In order to prevent hypoglycemia while continuing insulin therapy to reduce serum electrolyte concentrations, a typical infusion containing normal saline and 5% dextrose is commenced when glucose levels are below 12 mmol/L.
In some cases, normal saline combined with additional potassium may be required to prevent overcorrection of serum potassium levels and the development of hypokalemia. Monitoring potassium levels should be done between 4.0 – 5.5 mmol/L.
If a patient's consciousness level is concerning, alert a senior immediately and request help from an anaesthetist. In the meantime, re-assess the patient and ensure their airway is maintained.
If the patient loses consciousness and there are no signs of life present, call for help and commence CPR.
Remember to re-assess the patient after any intervention.
When assessing a patient, prioritize patient dignity and preservation of body heat. It may be necessary to expose the patient.
Check for evidence of self-injection sites and verify whether the patient is diabetic. Also inspect the urine in the catheter bag and note its appearance, as cloudy urine may signal a urinary tract infection. Additionally, inspect the patient's skin for any evidence of infection, such as cellulitis.
Measure the patient's temperature and take note if the fever is present. If the patient has been unconscious and exposed for a long period of time, they may be hypothermic.
Conduct urinalysis and send the sample for culture if a urinary tract infection is suspected, as this is a common DKA precipitant.
When infection is suspected, IV antibiotics should be given right away as indicated by local guidelines.
Catheterise the patient in order to accurately monitor urine output, fluid resuscitation, and potential necessity for escalation.
Use blankets to re-warm mild to moderately hypothermic patients. In the case of severe hypothermia, active re-warming techniques should be conducted.
If the patient is not responsive and there are no signs of life upon assessment, call for help and commence CPR.
Re-assess the patient utilizing the ABCDE approach to identify any changes in their condition and determine the effectiveness of previous interventions. Be sure to recognize and address any deterioration quickly.
If the patient shows no signs of improvement or if you have any concerns, seek help from a senior staff member and do not delay in doing so.
When assessing a patient with ABCDE, it is beneficial to have the help of another member of the clinical team, such as a nurse, who can take samples to the lab, catheterise, and perform observations as necessary.
Using an SBARR handover to communicate key information to other medical staff is an effective way of doing this.
Now that the patient has been stabilized and is doing much better, there are some more tasks that should be done.
Revisit history taking to explore relevant medical history and identify any causes for the DKA. If the patient is confused, it may be possible to get a collateral history from family members or staff.
Review the patient's notes, charts, and recent investigation results. Verify that the patient's medications are prescribed correctly.
Clearly document your ABCDE assessment including history, examination, observations, investigations, interventions, and the patient's response.
Discuss the patient's current condition with a senior clinician using an SBARR style handover. Include any causes of the DKA and involve the diabetes team in the patient's care.
Questions that may need to be considered include:
The shift doctors should be made aware of any patients in their department who have recently deteriorated.
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