Crucial Steps in the Initial Evaluation of Diabetic Ketoacidosis

Diabetic ketoacidosis is a dangerous medical condition that occurs in people with insulin-dependent type I diabetes, and rarely in people with noninsulin-dependent type II diabetes. Diabetic ketoacidosis is characterized by extremely high blood glucose levels, significant dehydration and low (acidic) pH of the body.

Diabetic ketoacidosis, or DKA, is a medical emergency. The initial management of a person in DKA, thus, should be initiated in the same manner as any other medical emergency. The management of any medical emergency begins with assessment of the ABCs: airway, breathing and circulation.

The patient in diabetic ketoacidosis may be confused or completely obtunded. They are often nauseous with vomiting episodes that could obstruct their airway. A person in DKA may display deep Kussmaul breathing (the body's attempt to correct the acidity of the body by releasing carbon dioxide) with a fruity acetone smell.

Once the patient is oxygenating well through a patent airway and is perfusing their body in a life-sustaining rhythm with IV access in place (or at least underway), the volume status and mental status should be assessed through physical examination and history taking.

During the history and physical exam, the physician should also try to determine the events that caused diabetic ketoacidosis in the individual. An easy way to remember the common causes of diabetic ketoacidosis is with the "6 I's". The "6 I's" causing diabetic ketoacidosis are:

-Infection

-Ingestion or Intoxication

-Ischemia (myocardial infarction, cardiovascular accident "stroke", ischemic intestines)

-Iatrogenic (caused by medical treatment, usually by prescription medications such as steroids)

-Impregnation (ie pregnancy)

-Insulin, the lack thereof (the most common cause of DKA is a type I diabetic not taking his or her insulin for whatever reason)

The mental status of an individual in diabetic ketoacidosis should always be assessed during the initial evaluation. Improvement in mental status from initial assessment is an important monitor indicating an improvement in the diabetic ketoacidosis. In contrast, a further decline in mental status can represent the rare, but life-threatening complication of cerebral edema that can occur during treatment of DKA.

Determining the initial volume status of an individual in diabetic ketoacidosis is also crucial. Individuals in diabetic ketoacidosis always require aggressive fluid resuscitation. But how aggressive, ie how fast fluids should be given, and how much fluid should be given, will vary with each individual.

A physician will evaluate the volume status of a diabetic in DKA by noting the degree of dry mucous membranes, poor skin turgor, sunken eyes, slow capillary refill, increased heart rate, thready or faint pulse, lack of tears and, in infants, a sunken fontanelle.

The initial evaluation of an individual who may be in DKA should be carried out in a thorough but expedited manner. Each of the components of the initial evaluation of DKA, basic life support ABCs, investigating the cause, noting the mental status and determining the degree of dehydration, are important in the successful management of individuals with diabetic ketoacidosis.