Diabetic Ketoacidosis (DKA) Clinical Presentation

Updated: May 31, 2019
  • Author: Osama Hamdy, MD, PhD; Chief Editor: Romesh Khardori, MD, PhD, FACP  more...
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Presentation

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.

A study by Crossen et al indicated that in children with type 1 diabetes, those who have had a recent emergency department visit and have undergone a long period without visiting an endocrinologist are more likely to develop DKA. The study included 5263 pediatric patients with type 1 diabetes. [15]

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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.

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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 rapid, shallow breathing (sigh breathing) that, as the acidosis grows more severe, becomes slower, deeper, and labored (air hunger), as well as 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. The breath has a fruity smell.

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.

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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

A prospective study by Jessup et al indicated that in pediatric patients with new-onset type 1 diabetes, those with severe, but uncomplicated, DKA tended to display lower cognitive functioning following correction of the DKA than did age-matched patients without DKA. The investigators suggested that DKA and/or its treatment produces a neuronal insult that causes “acute and possibly long-term cognitive deficits.” [16]  

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