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Pediatric Diabetic Ketoacidosis Emergency Department Care Workup

  • Author: Grace M Young, MD; Chief Editor: Stephen Kemp, MD, PhD  more...
Updated: Dec 16, 2015

Laboratory Studies

Serum glucose level

Serum glucose (eg, Accu-Chek, Dextrostix) determination of hyperglycemia provides the opportunity for rapid diagnosis and treatment of diabetic ketoacidosis (DKA). However, a urine analysis (dip for sugar and ketones) is also acceptable.

Serum potassium level

This is the most important electrolyte disturbance in patients with severe diabetic ketoacidosis.

A patient with a low serum potassium level should be assumed to have a potentially life-threatening total body potassium level.

Patients with evidence of hypovolemia or history of polydipsia who have normal or high serum potassium level should be assumed to have moderate total potassium depletion.

Therapy should begin with volume resuscitation.

As a result of the potential for hypokalemia-induced malignant dysrhythmias, do not give insulin to patients known to have profound potassium depletion until potassium replenishment is underway.

ABG level

Venous blood gases are an alternative and may be kinder for patients.

Historically, venous pH has been believed to overestimate the degree of acidosis because of decreased intravascular volume and increased peripheral lactic acidosis. However, an adult study of patients with diabetic ketoacidosis concluded that venous blood gases accurately demonstrated the degree of acidosis.

Glycosylated hemoglobin

In a patient with known diabetes, high percentages of glycosylated hemoglobin (Hgb A1C) indicate poor compliance with insulin therapy.

CBC count

Note that an increased WBC count may be a response to stress in diabetic ketoacidosis and not necessarily a sign of infection.

Other studies

Other studies include the following:

  • Obtain serum sodium, chloride, bicarbonate, BUN, creatinine, magnesium, calcium, and phosphate levels
  • Urine glucose, ketones, and osmolality
  • Serum osmolality
  • Blood, urine, and throat cultures

Imaging Studies

Obtain studies appropriate for suspected infection, obstructive abdominal processes, or cerebral edema.


Other Tests

An ECG is especially helpful when results of serum potassium concentration are not rapidly available. Hyperkalemia causes peaked T waves and cardiac dysrhythmias.

Any studies appropriate for suspected infections, toxidromes, or other metabolic abnormalities may be performed.



Establish 2 large intravenous catheter lines for fluids, insulin infusion, drips, and further venous sampling (use distal isolated dedicated saline lock for the latter purpose, which is kinder to patients).

Arterial catheterization is performed if the following conditions are present:

  • Profoundly altered mental status
  • Signs of severe shock
  • Signs of severe acidosis
Contributor Information and Disclosures

Grace M Young, MD Associate Professor, Department of Pediatrics, University of Maryland Medical Center

Grace M Young, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Emergency Physicians

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Wayne Wolfram, MD, MPH Professor, Department of Emergency Medicine, Mercy St Vincent Medical Center; Chairman, Pediatric Institutional Review Board, Mercy St Vincent Medical Center, Toledo, Ohio

Wayne Wolfram, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Pediatrics, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Stephen Kemp, MD, PhD Former Professor, Department of Pediatrics, Section of Pediatric Endocrinology, University of Arkansas for Medical Sciences College of Medicine, Arkansas Children's Hospital

Stephen Kemp, MD, PhD is a member of the following medical societies: American Academy of Pediatrics, American Association of Clinical Endocrinologists, American Pediatric Society, Endocrine Society, Phi Beta Kappa, Southern Medical Association, Southern Society for Pediatric Research

Disclosure: Nothing to disclose.

Additional Contributors

James Li, MD Former Assistant Professor, Division of Emergency Medicine, Harvard Medical School; Board of Directors, Remote Medicine

Disclosure: Nothing to disclose.

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Sample diabetic ketoacidosis flow sheet.
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