History and exam
Key diagnostic factors
common
known diabetes or features of diabetes
nausea and/or vomiting
abdominal pain
Examine the abdomen for a possible cause of DKA, such as pancreatitis.[15][30][47] DKA can both cause and mimic an acute abdomen.[49] DKA must be excluded prior to any emergency surgery.
Look for abdominal distension, which may indicate bowel obstruction.[82]
Palpate the abdomen to check for rebound tenderness and guarding caused by irritation of the peritoneum.[82]
Auscultate for bowel sounds.[83]
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.[82]
Ensure you take a chaperone with you.
Assess for occult or frank blood, pain, or a mass.
dehydration
Check for signs of dehydration. These are:[17]
Dry mucous membranes
Decreased skin turgor or skin wrinkling
Slow capillary refill
Tachycardia with a weak pulse
Hypotension.
hyperventilation
reduced consciousness
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.[2][66] [ Glasgow Coma Scale Opens in new window ]
Mental status can range from alert in mild DKA to coma in severe DKA.[52]
Cerebral oedema can develop during treatment of DKA due to rapid correction of hyperglycaemia.[2]
Signs include headache, irritability, slowing pulse, rising blood pressure, reducing conscious level. These may occur several hours after starting treatment.[3][60]
Papilloedema is a late sign of cerebral oedema.[3]
Involve immediate critical care input and give mannitol.[61]
Cerebral oedema has a mortality rate of 70%. It is most common in children and adolescents but can occur in adults.[4]
presence of risk factors
Infection
This is the most common cause of DKA.[1][2][26][33][35][36][52][70]
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.[4][17]
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.[71]
Inadequate insulin
Common reasons are:
New onset of diabetes[17]
A common cause of DKA.
Acute illness
Common causes include myocardial infarction, sepsis, and pancreatitis[15][30]
Maintain a high level of suspicion for myocardial infarction as patients with diabetes often present with atypical symptoms.
Physiological stress
This includes pregnancy, trauma, and surgery.
Practical tip
Diagnosis of DKA in pregnancy is often delayed because it can occur at lower blood glucose levels (including euglycaemic DKA) and faster than in non-pregnant patients.[2][76]
DKA in pregnancy may present with abdominal pain; always consider as a possible alternative to pre-term or term labour.[2]
DKA usually occurs in the second and third trimesters due to increased insulin resistance.[76] Pregnant women suspected of having DKA should receive care from both the obstetric and medical (or diabetes) teams.[2]
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.[1]
Drug history[17]
Drugs that may cause DKA include:
Corticosteroids (increase insulin resistance)[56]
Thiazides (unclear cause but may increase insulin resistance, inhibit glucose uptake, and decrease insulin release)
Sympathomimetics (alter glucose metabolism)[26]
Second-generation antipsychotics (alter glucose metabolism)[57]
Immune checkpoint inhibitors (cause insulin deficiency)[58]
Cocaine, cannabis, and acute intoxication with alcohol (DKA is associated with cocaine use but the mechanism is unclear)[55][59]
Sodium-glucose co-transporter 2 (SGLT2) inhibitors (prevent reabsorption of glucose and facilitate its excretion in urine).[21][22]
uncommon
hypothermia
Severe hypothermia is associated with a mortality rate of 30% to 60%.[67] Mild hypothermia may be seen in some patients with DKA due to peripheral vasodilation.[1]
Practical tip
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.[3]
Other diagnostic factors
common
acetone smell on breath
The patient’s breath smells like pear drops or nail varnish remover.[17] This is due to high ketone levels.
Practical tip
A significant proportion of people are unable to smell acetone even if it is present.
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