History and exam
Key diagnostic factors
Consider DKA in:
Look for abdominal distension, which may indicate bowel obstruction.
Palpate the abdomen to check for rebound tenderness and guarding caused by irritation of the peritoneum.
Auscultate for bowel sounds.
Hyperactive ‘tinkling’ bowel sounds may be present in early bowel obstruction.
Reduced or absent bowel sounds may be present in late bowel obstruction, perforated viscus, haemoperitoneum, or any cause of peritoneal inflammation.
Perform a rectal examination.
Ensure you take a chaperone with you.
Assess for occult or frank blood, pain, or a mass.
Check for signs of dehydration. These are:
Dry mucous membranes
Decreased skin turgor or skin wrinkling
Slow capillary refill
Tachycardia with a weak pulse
Assess conscious level hourly using the Glasgow Coma Scale to monitor for cerebral oedema. Reduced consciousness is strongly associated with more severe DKA and a worse prognosis. [ Glasgow Coma Scale ]
Mental status can range from alert in mild DKA to coma in severe DKA.
Cerebral oedema can develop during treatment of DKA due to rapid correction of hyperglycaemia.
Papilloedema is a late sign of cerebral oedema.
Involve immediate critical care input and give mannitol.
Cerebral oedema has a mortality rate of 70%. It is most common in children and adolescents but can occur in adults.
The most common causes are pneumonia and urinary tract infection.
Discontinuation of insulin (unintentional or deliberate)
Ask sensitively about reasons for deliberate discontinuation of insulin, which may include fear of weight gain or hypoglycaemia, financial barriers, and psychological factors such as needle phobia and stress.
Younger patients with type 1 diabetes may omit insulin due to fear of hypoglycemia, weight gain, eating disorders, or the stress of having a chronic disease. These factors may account for 20% of recurrent DKA.
Common reasons are:
New onset of diabetes
A common cause of DKA.
Maintain a high level of suspicion for myocardial infarction as patients with diabetes often present with atypical symptoms.
This includes pregnancy, trauma, and surgery.
Past medical history
History of diabetes:
DKA is most common in people with type 1 diabetes but can occur in those with type 2 diabetes.
Drugs that may cause DKA include:
Corticosteroids (increase insulin resistance)
Thiazides (unclear cause but may increase insulin resistance, inhibit glucose uptake, and decrease insulin release)
Sympathomimetics (alter glucose metabolism)
Second-generation antipsychotics (alter glucose metabolism)
Immune checkpoint inhibitors (cause insulin deficiency)
Fever is not a feature of DKA but DKA may be caused by sepsis. Suspect sepsis as a cause of DKA if there is fever or hypothermia, hypotension, refractory acidosis, or lactic acidosis.
Other diagnostic factors
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