Advanced•8 min read•High Yield

Diabetic Ketoacidosis (DKA) - CCS Case Guide

Key Takeaway: Diabetic ketoacidosis is a life-threatening complication of diabetes characterized by hyperglycemia, ketosis, and metabolic acidosis. Prompt recognition and aggressive management with IV fluids, insulin, and electrolyte repletion are essential.

Diabetic ketoacidosis is a life-threatening complication of diabetes characterized by hyperglycemia, ketosis, and metabolic acidosis. Prompt recognition and aggressive management with IV fluids, insulin, and electrolyte repletion are essential. This is one of the highest-yield CCS cases due to its multi-step, time-sensitive management.

Recognizing the DKA Presentation

  • History: Polyuria, polydipsia, nausea, vomiting, abdominal pain, and altered mental status in a known or new-onset diabetic
  • Physical Exam: Kussmaul respirations, fruity breath odor, dry mucous membranes, tachycardia, hypotension, and diffuse abdominal tenderness
  • Vital Signs: Tachycardia, hypotension, tachypnea, possible hypothermia

Immediate Actions (First 5 Minutes)

These orders should be placed immediately — timing is scored:

Critical First Orders

  • ✓ IV access with two large-bore IVs
  • ✓ Normal saline bolus 1-2 L over first hour
  • ✓ Stat BMP, CBC, ABG/VBG, urinalysis, serum ketones
  • ✓ Continuous telemetry monitoring
  • ✓ Fingerstick glucose every 1 hour

Complete Workup

After initial stabilization, complete the diagnostic workup:

  • BMP (glucose, potassium, bicarbonate, BUN/creatinine, anion gap)
  • CBC with differential
  • ABG or VBG
  • Serum ketones (beta-hydroxybutyrate)
  • Urinalysis with ketones
  • Serum phosphate and magnesium
  • Hemoglobin A1c
  • Lipase if abdominal pain prominent
  • Chest X-ray and blood cultures if infection suspected
  • ECG for potassium-related changes

Treatment

IV Fluids

  • NS 1-2 L bolus in first hour
  • Then NS at 250-500 mL/hr
  • Switch to D5 half-NS when glucose < 200 mg/dL

Insulin

  • Regular insulin IV bolus 0.1 units/kg
  • Continuous insulin drip at 0.1 units/kg/hr
  • Reduce drip rate when glucose < 200; do NOT stop drip until anion gap closes
  • Overlap with subcutaneous insulin 1-2 hours before stopping drip

Electrolyte Repletion

  • Hold insulin if K < 3.3 mEq/L; replete potassium first
  • Add 20-40 mEq KCl per liter of IV fluid if K 3.3-5.3
  • Monitor potassium every 2 hours
  • Replete phosphate if < 1.0 mg/dL

Bicarbonate

  • Consider only if pH < 6.9
  • 100 mEq NaHCO3 in 400 mL sterile water with 20 mEq KCl over 2 hours

Common Pitfalls

Scoring Tip: These are the most commonly missed actions for DKA cases.

  • Stopping insulin drip based on glucose alone instead of anion gap closure
  • Failing to check and replete potassium before starting insulin
  • Not switching to dextrose-containing fluids when glucose < 200
  • Forgetting to overlap subcutaneous insulin before stopping drip
  • Missing the underlying precipitant (infection, medication noncompliance, MI)

Disposition

  • Admit to ICU for continuous insulin drip and monitoring
  • Transfer to floor when anion gap closed, tolerating oral intake, and on subQ insulin
  • Diabetes education and endocrinology follow-up before discharge

Key Orders Checklist

  • ☐ Regular insulin drip
  • ☐ BMP every 2-4 hours
  • ☐ Fingerstick glucose every hour
  • ☐ Continuous telemetry
  • ☐ Strict I/O monitoring
  • ☐ NPO until stable

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