Diabetic Ketoacidosis Clinical Presentation

  • Author: Vasudevan A Raghavan, MBBS, MD, MRCP(UK); Chief Editor: George T Griffing, MD   more...
 
Updated: Jan 3, 2012
 

History

Insidious increased thirst (ie, polydipsia) and urination (ie, polyuria) are the most common early symptoms of diabetic ketoacidosis (DKA). Malaise, generalized weakness, and fatigability also can present as symptoms of DKA.

Nausea and vomiting usually occur and may be associated with diffuse abdominal pain, decreased appetite, and anorexia. A history of rapid weight loss is a symptom in patients who are newly diagnosed with type 1 diabetes.

Patients may present with a history of failure to comply with insulin therapy or missed insulin injections due to vomiting or psychological reasons. Decreased perspiration is another possible symptom of DKA.

Altered consciousness in the form of mild disorientation or confusion can occur. Although frank coma is uncommon, it may occur when the condition is neglected or if dehydration or acidosis is severe.

Among the symptoms of DKA associated with possible intercurrent infection are fever, dysuria, coughing, malaise, chills, chest pain, shortness of breath, and arthralgia. Acute chest pain or palpitation may occur in association with myocardial infarction. Painless infarction is not uncommon in patients with diabetes and should always be suspected in elderly patients.

Next

Physical Examination

General signs of diabetic ketoacidosis (DKA) may include the following:

  • Ill appearance
  • Dry skin
  • Labored respiration
  • Dry mucous membranes
  • Decreased skin turgor
  • Decreased reflexes
  • Characteristic acetone (ketotic) breath odor

Effects on vital signs that are related to DKA may include the following:

  • Tachycardia
  • Hypotension
  • Tachypnea
  • Hypothermia
  • Fever, if infection is present

Specific signs of DKA may include the following:

  • Confusion
  • Coma
  • Abdominal tenderness

The physical examination should also include detection of the signs of possible intercurrent illnesses such as myocardial infarction, urinary tract infection, pneumonia, and perinephric abscess. Search for signs of infection is mandatory in all cases.

Noticing that the body temperature may be within the reference range or low, even in the presence of intercurrent infection, is particularly important.

Previous
Next

Signs and Symptoms of Hyperglycemia, Acidosis, and Dehydration

Symptoms of hyperglycemia associated with diabetic ketoacidosis may include thirst, polyuria, polydipsia, and nocturia.

Signs of acidosis may include shallow rapid breathing or air hunger (Kussmaul or sighing respiration), abdominal tenderness, and disturbance of consciousness. Although these signs are not usual in all cases of diabetic ketoacidosis (DKA), their presence signifies a severe form of DKA.

Signs of dehydration include a weak and rapid pulse, dry tongue and skin, hypotension, and increased capillary refill time.

Emphasizing that no direct correlation exists between the degree of acidosis, hyperglycemia, and the disturbances in the level of consciousness is important.

Previous
Next

Complications Associated with DKA

Complications associated with DKA include sepsis and diffuse ischemic processes. Other associated complications include the following:

  • CVT
  • Myocardial infarction
  • DVT
  • Acute gastric dilatation
  • Erosive gastritis
  • Late hypoglycemia
  • Respiratory distress
  • Infection (most commonly, urinary tract infections)
  • Hypophosphatemia
  • Mucormycosis
  • Cerebrovascular accident
  • Complicated pregnancy
  • Trauma
  • Stress
  • Cocaine
  • Surgery
  • Heavy use of concentrated carbohydrate beverages (eg, sodas, sports drinks)
  • Acromegaly
  • Idiopathic condition (20-30%)
  • Dental abscess[11]
Previous
Proceed to Differential Diagnoses
 
 
Contributor Information and Disclosures
Author

Vasudevan A Raghavan, MBBS, MD, MRCP(UK)  Director, Cardiometabolic and Lipid (CAMEL) Clinic Services, Division of Endocrinology, Scott and White Hospital, Texas A&M Health Science Center College of Medicine

Vasudevan A Raghavan, MBBS, MD, MRCP(UK) is a member of the following medical societies: American College of Physicians-American Society of Internal Medicine, American Diabetes Association, American Heart Association, Endocrine Society, National Lipid Association, and Royal College of Physicians

Disclosure: Nothing to disclose.

Coauthor(s)

Howard A Bessen, MD  Professor of Medicine, Department of Emergency Medicine, University of California, Los Angeles, David Geffen School of Medicine; Program Director, Harbor-UCLA Medical Center

Howard A Bessen, MD is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Osama Hamdy, MD, PhD, FACE  Medical Director, Obesity Clinical Program, Director of Inpatient Diabetes Management, Joslin Diabetes Center; Assistant Professor of Medicine, Harvard Medical School

Osama Hamdy, MD, PhD, FACE is a member of the following medical societies: American Association of Clinical Endocrinologists and American Diabetes Association

Disclosure: Merck Inc Honoraria Speaking and teaching

Donald W Rucker, MD, MBA, MS  Clinical Assistant Professor of Emergency Medicine, University of Pennsylvania School of Medicine

Donald W Rucker, MD, MBA, MS is a member of the following medical societies: American College of Emergency Physicians, American College of Physicians, American Medical Association, American Medical Informatics Association, and Society for Academic Emergency Medicine

Disclosure: Siemens Healthcare Salary Employment

Erik D Schraga, MD  Staff Physician, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates

Disclosure: Nothing to disclose.

Specialty Editor Board

David S Schade, MD  Chief, Division of Endocrinology and Metabolism, Professor, Department of Internal Medicine, University of New Mexico School of Medicine and Health Sciences Center

David S Schade, MD is a member of the following medical societies: American College of Physicians, American Diabetes Association, American Federation for Medical Research, Endocrine Society, New Mexico Medical Society, New York Academy of Sciences, and Society for Experimental Biology and Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Don S Schalch, MD  Professor Emeritus, Department of Internal Medicine, Division of Endocrinology, University of Wisconsin Hospitals and Clinics

Don S Schalch, MD is a member of the following medical societies: American Diabetes Association, American Federation for Medical Research, Central Society for Clinical Research, and Endocrine Society

Disclosure: Nothing to disclose.

Barry E Brenner, MD, PhD, FACEP  Professor of Emergency Medicine, Professor of Internal Medicine, Program Director, Emergency Medicine, Case Medical Center, University Hospitals, Case Western Reserve University School of Medicine

Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians, American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York Academy of Sciences, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

George T Griffing, MD  Professor of Medicine, St Louis University School of Medicine

George T Griffing, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Medical Practice Executives, American College of Physician Executives, American College of Physicians, American Diabetes Association, American Federation for Medical Research, American Heart Association, Central Society for Clinical Research, Endocrine Society, International Society for Clinical Densitometry, and Southern Society for Clinical Investigation

Disclosure: Nothing to disclose.

References

  1. Herrington WG, Nye HJ, Hammersley MS, Watkinson PJ. Are arterial and venous samples clinically equivalent for the estimation of pH, serum bicarbonate and potassium concentration in critically ill patients?. Diabet Med. Jan 2012;29(1):32-5. [Medline].

  2. Mrozik LT, Yung M. Hyperchloraemic metabolic acidosis slows recovery in children with diabetic ketoacidosis: a retrospective audit. Aust Crit Care. Jun 26 2009;[Medline].

  3. Bowden SA, Duck MM, Hoffman RP. Young children (< 5 yr) and adolescents (>12 yr) with type 1 diabetes mellitus have low rate of partial remission: diabetic ketoacidosis is an important risk factor. Pediatr Diabetes. Jun 2008;9(3 Pt 1):197-201. [Medline].

  4. Potenza M, Via MA, Yanagisawa RT. Excess thyroid hormone and carbohydrate metabolism. Endocr Pract. May-Jun 2009;15(3):254-62. [Medline].

  5. Zargar AH, Wani AI, Masoodi SR, et al. Causes of mortality in diabetes mellitus: data from a tertiary teaching hospital in India. Postgrad Med J. May 2009;85(1003):227-32. [Medline].

  6. Usher-Smith JA, Thompson MJ, Sharp SJ, Walter FM. Factors associated with the presence of diabetic ketoacidosis at diagnosis of diabetes in children and young adults: a systematic review. BMJ. Jul 7 2011;343:d4092. [Medline].

  7. Lin SF, Lin JD, Huang YY. Diabetic ketoacidosis: comparisons of patient characteristics, clinical presentations and outcomes today and 20 years ago. Chang Gung Med J. Jan 2005;28(1):24-30. [Medline].

  8. Glaser NS, Marcin JP, Wootton-Gorges SL, et al. Correlation of clinical and biochemical findings with diabetic ketoacidosis-related cerebral edema in children using magnetic resonance diffusion-weighted imaging. J Pediatr. Jun 25 2008;[Medline].

  9. Pugliese G, Zanuso S, Alessi E, et al. Self glucose monitoring and physical exercise in diabetes. Diabetes Metab Res Rev. Sep 2009;25 Suppl 1:S11-7. [Medline].

  10. Weber C, Kocher S, Neeser K, et al. Prevention of diabetic ketoacidosis and self-monitoring of ketone bodies: an overview. Curr Med Res Opin. May 2009;25(5):1197-207. [Medline].

  11. Chandu A, Macisaac RJ, Smith AC, Bach LA. Diabetic ketoacidosis secondary to dento-alveolar infection. Int J Oral Maxillofac Surg. Feb 2002;31(1):57-9. [Medline].

  12. Arora S, Henderson SO, Long T, Menchine M. Diagnostic Accuracy of Point-of-Care Testing for Diabetic Ketoacidosis at Emergency-Department Triage: {beta}-Hydroxybutyrate versus the urine dipstick. Diabetes Care. Apr 2011;34(4):852-4. [Medline]. [Full Text].

  13. Savage MW, Dhatariya KK, Kilvert A, Rayman G, Rees JA, Courtney CH, et al. Joint British Diabetes Societies guideline for the management of diabetic ketoacidosis. Diabet Med. May 2011;28(5):508-15. [Medline].

  14. Joint British Diabetes Societies Inpatient Care Group. The Management of Diabetic Ketoacidosis in Adults. March 2010. Available at http://www.diabetes.nhs.uk/document.php?o=1336. Accessed June 27, 2011.

  15. Wallace TM, Matthews DR. Recent advances in the monitoring and management of diabetic ketoacidosis. QJM. Dec 2004;97(12):773-80. [Medline].

  16. Ma OJ, Rush MD, Godfrey MM, Gaddis G. Arterial blood gas results rarely influence emergency physician management of patients with suspected diabetic ketoacidosis. Acad Emerg Med. Aug 2003;10(8):836-41. [Medline].

  17. Brandenburg MA, Dire DJ. Comparison of arterial and venous blood gas values in the initial emergency department evaluation of patients with diabetic ketoacidosis. Ann Emerg Med. Apr 1998;31(4):459-65. [Medline].

  18. Goyal N, Miller JB, Sankey SS, Mossallam U. Utility of initial bolus insulin in the treatment of diabetic ketoacidosis. J Emerg Med. May 2010;38(4):422-7. [Medline].

  19. [Guideline] Wolfsdorf J, Craig ME, Daneman D, Dunger D, Edge J, Lee WR, et al. Diabetic ketoacidosis. Pediatr Diabetes. Feb 2007;8(1):28-43. [Medline].

  20. Glaser NS, Wootton-Gorges SL, Buonocore MH, Marcin JP, Rewers A, Strain J, et al. Frequency of sub-clinical cerebral edema in children with diabetic ketoacidosis. Pediatr Diabetes. Apr 2006;7(2):75-80. [Medline].

  21. Muir AB, Quisling RG, Yang MC, Rosenbloom AL. Cerebral edema in childhood diabetic ketoacidosis: natural history, radiographic findings, and early identification. Diabetes Care. Jul 2004;27(7):1541-6. [Medline].

  22. Hom J, Sinert R. Evidence-based emergency medicine/critically appraised topic. Is fluid therapy associated with cerebral edema in children with diabetic ketoacidosis?. Ann Emerg Med. Jul 2008;52(1):69-75.e1. [Medline].

  23. Bradley P, Tobias JD. An evaluation of the outside therapy of diabetic ketoacidosis in pediatric patients. Am J Ther. Nov-Dec 2008;15(6):516-9. [Medline].

  24. Umpierrez GE, Jones S, Smiley D, et al. Insulin analogs versus human insulin in the treatment of patients with diabetic ketoacidosis: a randomized controlled trial. Diabetes Care. Jul 2009;32(7):1164-9. [Medline].

  25. Ai D, Roper TA, Riley JA. Diabetic ketoacidosis and clozapine. Postgrad Med J. Aug 1998;74(874):493-4. [Medline].

  26. Amemiya S. Constant infused glucose regimen during the recovery phase of diabetic ketoacidosis in children and adolescents with IDDM. Diabetes Care. Apr 1998;21(4):676-7. [Medline].

  27. Bohan JS. Chemical measurements in ketoacidosis. Arch Intern Med. Sep 27 1999;159(17):2089. [Medline].

  28. Brink SJ. Diabetic ketoacidosis: prevention, treatment and complications in children and adolescents. Diabetes Nutr Metab. Apr 1999;12(2):122-35. [Medline].

  29. Carroll MA, Yeomans ER. Diabetic ketoacidosis in pregnancy. Crit Care Med. Oct 2005;33(10 Suppl):S347-53. [Medline].

  30. Catalano C, Fabbian F, Di Landro D. Acute pulmonary oedema occurring in association with diabetic ketoacidosis in a diabetic patient with chronic renal failure. Nephrol Dial Transplant. Feb 1998;13(2):491-2. [Medline].

  31. Charfen MA, Fernández-Frackelton M. Diabetic ketoacidosis. Emerg Med Clin North Am. Aug 2005;23(3):609-28, vii. [Medline].

  32. [Best Evidence] Della Manna T, Steinmetz L, Campos PR, Farhat SC, Schvartsman C, Kuperman H. Subcutaneous use of a fast-acting insulin analog: an alternative treatment for pediatric patients with diabetic ketoacidosis. Diabetes Care. Aug 2005;28(8):1856-61. [Medline].

  33. Edge JA, Ford-Adams ME, Dunger DB. Causes of death in children with insulin dependent diabetes 1990-96. Arch Dis Child. Oct 1999;81(4):318-23. [Medline].

  34. Fearon DM, Steele DW. End-tidal carbon dioxide predicts the presence and severity of acidosis in children with diabetes. Acad Emerg Med. Dec 2002;9(12):1373-8. [Medline].

  35. Fisken RA. Severe diabetic ketoacidosis: the need for large doses of insulin. Diabet Med. Apr 1999;16(4):347-50. [Medline].

  36. Glaser N, Barnett P, McCaslin I, Nelson D, Trainor J, Louie J, et al. Risk factors for cerebral edema in children with diabetic ketoacidosis. The Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics. N Engl J Med. Jan 25 2001;344(4):264-9. [Medline].

  37. Green SM, Rothrock SG, Ho JD, Gallant RD, Borger R, Thomas TL, et al. Failure of adjunctive bicarbonate to improve outcome in severe pediatric diabetic ketoacidosis. Ann Emerg Med. Jan 1998;31(1):41-8. [Medline].

  38. Grimberg A, Cerri RW, Satin-Smith M, Cohen P. The "two bag system" for variable intravenous dextrose and fluid administration: benefits in diabetic ketoacidosis management. J Pediatr. Mar 1999;134(3):376-8. [Medline].

  39. Hjort U, Christensen JH. Diabetic ketoacidosis and compliance. Lancet. Feb 28 1998;351(9103):674-5. [Medline].

  40. Hoffman WH, Locksmith JP, Burton EM, et al. Interstitial pulmonary edema in children and adolescents with diabetic ketoacidosis. J Diabetes Complications. 12(6):314-20. [Medline].

  41. Kannan CR. Bicarbonate therapy in the management of severe diabetic ketoacidosis. Crit Care Med. Dec 1999;27(12):2833-4. [Medline].

  42. Kaufman FR, Halvorson M. The treatment and prevention of diabetic ketoacidosis in children and adolescents with type I diabetes mellitus. Pediatr Ann. Sep 1999;28(9):576-82. [Medline].

  43. Kaufman FR, Halvorson M, Fisher L, Pitukcheewanont P. Insulin pump therapy in type 1 pediatric patients. J Pediatr Endocrinol Metab. 1999;12 Suppl 3:759-64. [Medline].

  44. Kitabchi AE, Nyenwe EA. Hyperglycemic crises in diabetes mellitus: diabetic ketoacidosis and hyperglycemic hyperosmolar state. Endocrinol Metab Clin North Am. Dec 2006;35(4):725-51, viii. [Medline].

  45. Kreshak A, Chen EH. Arterial blood gas analysis: are its values needed for the management of diabetic ketoacidosis?. Ann Emerg Med. May 2005;45(5):550-1. [Medline].

  46. Laffel L. Ketone bodies: a review of physiology, pathophysiology and application of monitoring to diabetes. Diabetes Metab Res Rev. Nov-Dec 1999;15(6):412-26. [Medline].

  47. Liss DS, Waller DA, Kennard BD, McIntire D, Capra P, Stephens J. Psychiatric illness and family support in children and adolescents with diabetic ketoacidosis: a controlled study. J Am Acad Child Adolesc Psychiatry. May 1998;37(5):536-44. [Medline].

  48. Mahoney CP, Vlcek BW, DelAguila M. Risk factors for developing brain herniation during diabetic ketoacidosis. Pediatr Neurol. Oct 1999;21(4):721-7. [Medline].

  49. Martin SL, Hoffman WH, Marcus DM, Passmore GG, Dalton RR. Retinal vascular integrity following correction of diabetic ketoacidosis in children and adolescents. J Diabetes Complications. Jul-Aug 2005;19(4):233-7. [Medline].

  50. McDonnell CM, Pedreira CC, Vadamalayan B, Cameron FJ, Werther GA. Diabetic ketoacidosis, hyperosmolarity and hypernatremia: are high-carbohydrate drinks worsening initial presentation?. Pediatr Diabetes. Jun 2005;6(2):90-4. [Medline].

  51. Moller N, Foss AC, Gravholt CH, Mortensen UM, Poulsen SH, Mogensen CE. Myocardial injury with biomarker elevation in diabetic ketoacidosis. J Diabetes Complications. Nov-Dec 2005;19(6):361-3. [Medline].

  52. Newton CA, Raskin P. Diabetic ketoacidosis in type 1 and type 2 diabetes mellitus: clinical and biochemical differences. Arch Intern Med. Sep 27 2004;164(17):1925-31. [Medline].

  53. Paton RC, Sathiavageeswaran M. Severe diabetic ketoacidosis. Diabet Med. Oct 1999;16(10):884. [Medline].

  54. Reichel A, Rietzsch H, Kohler HJ, Pfutzner A, Gudat U, Schulze J. Cessation of insulin infusion at night-time during CSII-therapy: comparison of regular human insulin and insulin lispro. Exp Clin Endocrinol Diabetes. 1998;106(3):168-72. [Medline].

  55. Smith CP, Firth D, Bennett S, Howard C, Chisholm P. Ketoacidosis occurring in newly diagnosed and established diabetic children. Acta Paediatr. May 1998;87(5):537-41. [Medline].

  56. Timmons JA, Myer P, Maturen A, et al. Use of beta-hydroxybutyric acid levels in the emergency department. Am J Ther. May 1998;5(3):159-63. [Medline].

  57. Umpierrez GE, Cuervo R, Karabell A, Latif K, Freire AX, Kitabchi AE. Treatment of diabetic ketoacidosis with subcutaneous insulin aspart. Diabetes Care. Aug 2004;27(8):1873-8. [Medline].

  58. Umpierrez GE, Smiley D, Kitabchi AE. Narrative review: ketosis-prone type 2 diabetes mellitus. Ann Intern Med. Mar 7 2006;144(5):350-7. [Medline].

  59. Viallon A, Zeni F, Lafond P, et al. Does bicarbonate therapy improve the management of severe diabetic ketoacidosis?. Crit Care Med. Dec 1999;27(12):2690-3. [Medline].

  60. Wagner A, Risse A, Brill HL, et al. Therapy of severe diabetic ketoacidosis. Zero-mortality under very-low-dose insulin application. Diabetes Care. May 1999;22(5):674-7. [Medline].

  61. Warner EA, Greene GS, Buchsbaum MS, Cooper DS, Robinson BE. Diabetic ketoacidosis associated with cocaine use. Arch Intern Med. Sep 14 1998;158(16):1799-802. [Medline].

  62. Whiteman VE, Homko CJ, Reece EA. Management of hypoglycemia and diabetic ketoacidosis in pregnancy. Obstet Gynecol Clin North Am. Mar 1996;23(1):87-107. [Medline].

  63. Wolfsdorf J, Glaser N, Sperling MA. Diabetic ketoacidosis in infants, children, and adolescents: A consensus statement from the American Diabetes Association. Diabetes Care. May 2006;29(5):1150-9. [Medline].

  64. Yan SH, Sheu WH, Song YM, Tseng LN. The occurrence of diabetic ketoacidosis in adults. Intern Med. Jan 2000;39(1):10-4. [Medline].

  65. Younis N, Austin MJ, Casson IF. A respiratory complication of diabetic ketoacidosis. Postgrad Med J. Dec 1999;75(890):753-4. [Medline].

 
Previous
Next
 
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.