# Diabetic Ketoacidosis (Emergency Referral) - Category: emergency - Review status: reviewed (every claim checked against a document named on this page) - Sources: Adult Diabetic Ketoacidosis - StatPearls, updated 30 November 2025 - https://www.ncbi.nlm.nih.gov/books/NBK560723/ - Verified date: 2026-08 ## Verified against - Adult Diabetic Ketoacidosis - StatPearls, updated 30 November 2025 - https://www.ncbi.nlm.nih.gov/books/NBK560723/ ## Treatment metadata - Insulin neutral human — injection - Referral & safety-netting (no drug therapy) ## Complete treatment card ```text DIABETIC KETOACIDOSIS (EMERGENCY REFERRAL) Sources: Adult Diabetic Ketoacidosis - StatPearls, updated 30 November 2025 - https://www.ncbi.nlm.nih.gov/books/NBK560723/ Review status: REVIEWED against the source listed above (2026-08) IS IT THIS? - reference only, to read alongside your own examination SYMPTOMS - what the patient reports (5) - Excess hunger, urination, and thirst can signal underlying hyperglycemia [hyperglycaemia] - Reduced urine output, a dry mouth, and decreased sweating point to worsening dehydration [dehydration · dry mouth · sweating] - Loss of appetite, nausea, vomiting, abdominal pain, and weight loss are commonly reported [abdominal pain · nausea · poor appetite · vomiting · weight loss] - Fever, cough, or urinary complaints may appear when an infection has triggered the episode [cough · fever] - Headache or confusion can signal evolving cerebral edema [confusion · headache · oedema] SIGNS - what you find (8) - Vital signs often show a fast heart rate and rapid breathing [tachycardia · tachypnoea] - Fever or low body temperature may be seen when an infection underlies the episode [fever · hypothermia] - Low blood pressure can occur and marks a more severe course [hypotension] - Deep, labored, rapid breathing (Kussmaul respirations) may be seen [tachypnoea] - A fruity breath odor from acetone may be noticeable on exam - Poor capillary refill, reduced skin turgor, and dry mucous membranes reflect dehydration [dehydration] - Abdominal tenderness may be found on exam [abdominal tenderness] - Altered mental status, drowsiness, and focal neurologic deficits mark the most severe cerebral edema [drowsiness · oedema] TESTS (11) - Diagnosis requires glucose above 250 mg/dL, arterial pH under 7.3, bicarbonate under 15 mEq/L, and ketonemia or ketonuria - An anion gap over 14 to 15 mEq/L marks an elevated anion-gap metabolic acidosis - Glucose can be only mildly raised, under 300 mg/dL, in those prone to hypoglycemia such as insulin or SGLT2-inhibitor users - Most patients show a raised white cell count even without an infection - Measured serum sodium reads falsely low and must be corrected for the glucose level - Serum potassium is typically raised even though whole-body stores are depleted - Serum phosphate may look elevated despite overall body phosphate depletion - The 3-beta-hydroxybutyrate to acetoacetate ketone ratio rises from a normal 1:1 up to as much as 10:1 - ECG changes such as peaked T waves point to hyperkalemia, while flattened T waves with a U wave point to hypokalemia - A chest x-ray may be obtained to exclude pulmonary consolidation - CT of the brain can identify significant cerebral edema when it is suspected IF NOT THIS - what else fits (10) - Hyperosmolar hyperglycemic nonketotic syndrome is on the differential - Starvation ketosis is a differential to consider - Myocardial infarction is on the differential list - Pancreatitis is a differential to consider - Alcoholic ketoacidosis is a differential to rule out - Lactic acidosis is a differential to consider - Sepsis is a differential to consider - Toxicologic exposure such as ethylene glycol, methanol, paraldehyde, or salicylate is a differential - Diabetic medication overdose is a differential to consider - Uremia is a differential to consider Source StatPearls "Adult Diabetic Ketoacidosis" - disease-level clinical article Status traced to the source above Rx: Insulin | Main treatment INSULIN 1. INSULIN NEUTRAL HUMAN [1st line] Adult CHECK POTASSIUM FIRST - do not start insulin until serum potassium is above 3.5 mmol/L. Then intravenous infusion at 0.14 units/kg/hour with no bolus, or a 0.1 units/kg bolus followed by 0.1 units/kg/hour. Drop to 0.05 units/kg/hour once glucose reaches 200 to 250 mg/dL, with dextrose added to the fluids. - Continued until the ketoacidosis resolves, and for 2 hours after subcutaneous insulin is started Peds The article gives no separate paediatric regimen, so none is printed. What it does say about children is a warning rather than a dose: rates of cerebral oedema rose with aggressive fluid volumes particularly in children, and in a paediatric study the children at higher risk of cerebral oedema were those presenting with a low PaCO2 and a high blood urea nitrogen, and those treated with bicarbonate. A child in DKA is managed on a paediatric protocol by the unit that admits them. Source Adult Diabetic Ketoacidosis - StatPearls, updated 30 November 2025 - https://www.ncbi.nlm.nih.gov/books/NBK560723/ Why The cited article states that intravenous insulin by continuous infusion is the standard of care, and gives both regimens: an initial bolus of 0.1 units/kg followed by an infusion of 0.1 units/kg/hour, or - on a more recent randomised trial it names - an hourly infusion of 0.14 units/kg/hour with no bolus at all. It states that the rate may need to fall to 0.05 units/kg/hour once plasma glucose reaches 200 to 250 mg/dL and dextrose-containing fluid is started, and that in euglycaemic DKA no bolus is given and the infusion runs at 0.05 units/kg/hour from the start with 5% to 10% dextrose in the fluids throughout. Caution POTASSIUM BEFORE INSULIN, EVERY TIME. The article states that insulin should only be started when serum potassium is 3.5 mmol/L or higher, because insulin drives potassium into the cells and can produce severe hypokalaemia - cardiac arrhythmia, cardiac arrest, and respiratory arrest from respiratory muscle weakness. Below 3.5 mmol/L the patient gets fluid and potassium first, and insulin waits. AND POTASSIUM ALONGSIDE IT AFTERWARDS. The article starts potassium replacement once the serum level is below 5.2 mEq/L, aiming to hold it between 4 and 5 mEq/L, at 20 to 30 mEq per litre of fluid for most patients and less in acute or chronic renal failure. EUGLYCAEMIC DKA IS REAL AND THE REGIMEN IS DIFFERENT. The article describes DKA with a glucose below 250 mg/dL, gives no bolus in it, runs the infusion at 0.05 units/kg/hour, and puts 5% to 10% dextrose in the fluids from the beginning. THIS IS AN AMBULANCE, NOT A CLINIC. Insulin here is an intravenous infusion titrated against hourly glucose, potassium and the anion gap. The regimen is printed so the GP knows what the patient is being sent for and can recognise it - not so it is started in the surgery. MILD, UNCOMPLICATED DKA HAS A SUBCUTANEOUS ALTERNATIVE, AND IT IS A DIFFERENT INSULIN. The article gives subcutaneous lispro 0.1 units/kg initially then 0.1 units/kg hourly until glucose is under 250 mg/dL, then 0.1 units/kg hourly or 0.2 units/kg every 2 hours until the DKA resolves, and says aspart has been found equally effective. That is a non- intensive-care regimen for a mild case, not a substitute for the infusion in a sick patient. DO NOT STOP THE INFUSION THE MOMENT SUBCUTANEOUS INSULIN GOES IN. The article asks for the infusion to continue for 2 hours after the first subcutaneous dose, to stop the ketoacidosis recurring in the gap. Egypt HUMAN INSULIN R VACSERA-BIOTON 100I.U./ML VIAL VACSERA > BIOTON CO. LTD-... 31.00 EGP INSUMAN RAPID 100 I.U./ML 10ML VIAL SANOFI > FRANCO 55.00 EGP INSULIN H BIO R 100I.U.VIAL SEDICO 77.00 EGP ACTRAPID HM 100 I.U./ML 10 ML VIAL NOVO NORDISK 130.00 EGP INSUMAN RAPID 100 I.U./ML 5*3ML PENFILLS SANOFI > FRANCO 133.00 EGP HUMAXIN RAPID 100 I.U./ML 5*3ML PENFILLS EVA PHARMA 322.00 EGP ACTRAPID HM 100 I.U./ML 5*3ML PENFILLS NOVO NORDISK 338.00 EGP HUMULIN R 100 I.U./ML 5 CARTRIDGE ELI LILLY 338.00 EGP MAIN TREATMENT 2. REFERRAL & SAFETY-NETTING (NO DRUG THERAPY) [1st line] Adult Emergency admission, now. Thirst, polyuria and weight loss progressing to vomiting, abdominal pain, deep sighing (Kussmaul) breathing and a fruity smell on the breath. Diagnosis is glucose above 250 mg/dL, arterial pH below 7.3, bicarbonate below 15 mEq/L, and ketones in blood or urine. Check a capillary glucose and ketones if you can, but a patient who looks like this goes to hospital whether or not you can measure them. - Refer, with advice Peds Children decompensate faster and are at risk of cerebral oedema during treatment. Emergency transfer; do not attempt rehydration protocols in the clinic. Source No dose - referral pathway, no medicine given in primary care Caution HOSPITAL ONLY. StatPearls: intravenous insulin by continuous infusion is the standard of care, with hourly glucose monitoring. There is no outpatient version of this. DO NOT give insulin before potassium is known. StatPearls requires a potassium of at least 3.5 mmol/L before insulin is started - giving insulin first can cause fatal hypokalaemia. It can be the FIRST presentation of diabetes. A previously well young person with these symptoms has new type 1 diabetes until proved otherwise - see [Type 1 Diabetes]. Infection, missed insulin doses, corticosteroids, thiazides and SGLT-2 inhibitors are the common precipitants. SGLT-2 inhibitors can produce ketoacidosis with a near-normal glucose. Abdominal pain in DKA is often taken for a surgical abdomen. Check ketones before referring the pain instead of the patient. Prices are indicative (dataset snapshot 2026-06); verify with the pharmacy. ``` --- Dawaa Reference is a reference for prescribers, not a medical device, and does not replace clinical judgement. [Privacy policy](/privacy)