Diabetic ketoacidosis

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Target exams

Red flags

• Headache, a falling conscious level, irritability or drowsiness, incontinence, or a rising blood pressure with a falling heart rate in a child being treated for DKA signals cerebral oedema — act within minutes, do not wait for a scan
• A child in DKA who is volume depleted needs 10 to 20 millilitres per kilogram of isotonic saline over 20 to 30 minutes (20 millilitres per kilogram if perfusion is poor; 20 millilitre per kilogram boluses rapidly if shocked), reassessed after each — but grossly excessive fluids and rapid osmolar shifts remain a danger to the brain
• Serum potassium is normal or high at presentation despite a large total-body potassium deficit; it will fall sharply once insulin and fluids begin, so replace potassium early and monitor it hourly
• Never give an intravenous insulin bolus to a child in DKA and never start insulin before fluid resuscitation has begun — both increase the risk of a dangerous osmotic shift and cerebral oedema
• The young child (under five years), new-onset diabetes, severe acidosis, and a markedly raised urea are the classic high-risk features for cerebral oedema
• Kussmaul breathing and the sweet smell of ketones on the breath in a drowsy, dehydrated child are DKA until proven otherwise — check a glucose and a blood ketone at once
• Abdominal pain and vomiting in DKA can mimic a surgical abdomen; treat the acidosis first and reassess, because the pain usually resolves as the acidosis clears

Life stages

Care settings

Clinical exam formats

Board mappings

• Recognition and biochemical diagnosis of diabetic ketoacidosis in a child
• The ISPAD fluid and insulin protocol for paediatric DKA
• Recognition and emergency management of cerebral oedema
• Pathophysiology of ketoacidosis and the potassium paradox
• Evidence on fluid rate and tonicity from the PECARN FLUID trial
• Resolution criteria and safe transition to subcutaneous insulin
• Managing new-onset DKA in a district hospital before retrieval
• Preventing DKA through sick-day rules and early presentation
• Recognising the deteriorating child during DKA treatment
• Acute short case of the dehydrated, acidotic child with Kussmaul breathing
• Long case of recurrent DKA in an adolescent exploring adherence, mental health and social risk
• Acute metabolic emergencies of diabetes
• Fluid and electrolyte management in the acutely ill child
• Neurological deterioration during DKA
• Biochemistry of ketogenesis and high anion gap acidosis
• Diagnostic criteria and severity grading of DKA
• Pharmacology and physiology of insulin and potassium replacement
• Resuscitation and monitoring of the child in DKA
• Communicating the diagnosis of new-onset diabetes to a family
• Diagnosis and management of diabetic ketoacidosis
• Cerebral edema recognition and treatment
• Fluid and electrolyte therapy in DKA
• Acute management of pediatric DKA
• Cerebral edema and neurologic monitoring
• Transition from intravenous to subcutaneous insulin
• Emergency management of diabetic ketoacidosis in children
• Pathophysiology and electrolyte derangements of DKA
• Prevention of recurrent DKA and cerebral injury