🚑 DKA = medical emergency. Treat the triad (hyperglycaemia, ketonaemia, acidosis) and actively hunt the trigger. Don’t miss 🦠 sepsis, ❤️ MI, 🫀 pancreatitis, or 🤰 pregnancy—these kill patients if untreated.

🧑‍⚕️ OSCE Checklist — DKA with Triggers Integrated

1) ABCDE First

Airway safe? Breathing: O₂ only if SpO₂ <94%.
Circulation: 2× large-bore IV, continuous ECG, BP, SpO₂, strict urine output (catheter if needed).
Disability: GCS, capillary glucose + ketones.
Exposure: look for infection sources (chest, urine, skin/lines, wounds).

2) Confirm DKA (the Triad)

💉 Glucose > 11 mmol/L (or known diabetes)
⚡ Blood ketones > 3.0 mmol/L (or urine ≥ 2+)
🧪 Acidosis: VBG pH < 7.3 or HCO₃ < 15 mmol/L

3) Immediate Tests (Bedside + Labs)

Bedside: CBG, capillary ketones, VBG (pH/HCO₃/K⁺/lactate), ECG.
Bloods: FBC, U&E, LFTs, CRP, cultures (if sepsis suspected), troponin (now ± repeat), lipase (± amylase), β-hCG in women with childbearing potential.
CXR if respiratory symptoms/signs; urine dip ± culture.

4) Fluids (adult template, individualise)

If SBP < 90 mmHg: 500 mL 0.9% saline over 10–15 min; repeat until SBP > 90.
Then ~6 L 0.9% saline over 18 h for a 70 kg adult (1 L/1 h → 1 L/2 h ×2 → 1 L/4 h ×2 → 1 L/6 h), adding K⁺ as below.
Use caution/closer monitoring in young, elderly, pregnancy, renal/cardiac disease.

5) Potassium (replace early, monitor hourly initially)

Serum K⁺ (mmol/L)	Ward-level action
> 5.5	No KCl added (recheck K⁺ in 1 h)
3.5 – 5.5	Add 40 mmol KCl per litre of 0.9% saline
< 3.5	Give 40 mmol/L and seek senior review (may need higher-rate/CCU)

6) Insulin & Glucose

Start FRIII: 0.1 units/kg/h IV (e.g., 50 units Actrapid in 50 mL 0.9% saline). No IV bolus.
Continue basal (long-acting) insulin (e.g., glargine/detemir) at usual dose.
When CBG < 14 mmol/L: commence 10% glucose at 125 mL/h alongside saline to allow ongoing ketone clearance with insulin.

7) Sepsis — Don’t Miss It (do within 1 hour if suspected)

Sepsis Six (UK):

Give high-flow O₂ if hypoxic.
Take blood cultures (± urine/sputum cultures).
Give IV broad-spectrum antibiotics within 1 hour (per local policy).
Give IV fluids (part of DKA resus).
Check lactate and full labs; repeat if high.
Monitor urine output.

Choose antibiotics according to local guidelines, suspected source, allergies, and AKI risk.

8) MI — Screen Early

12-lead ECG on arrival ± repeat at 2–3 h if ongoing concern.
High-sensitivity troponin now and per local ACS pathway.
If ACS likely: involve cardiology; balance fluids carefully if cardiac compromise.

9) Other Triggers to Act On

🫀 Pancreatitis: lipase (preferred) ± amylase, triglycerides; abdominal US if biliary suspicion.
🤰 Pregnancy: urgent obstetric input; tighter fluid balance; fetal monitoring if viable gestation.
Missed insulin/psychosocial factors: diabetes CNS review before discharge.

10) Monitoring & Targets

Hourly CBG and ketones; VBG 2–4 hourly; strict fluids in/out; obs (HR, BP, RR, SpO₂, GCS).
Targets: ketones ↓ ≥ 0.5 mmol/L/h; glucose ↓ ≥ 3 mmol/L/h; K⁺ 4–5.5 mmol/L.
Resolution: ketones < 0.3 mmol/L, pH > 7.3, HCO₃ > 15, patient eating/drinking.

11) Step-down & Transition to SC Insulin

When resolving and able to eat: give rapid-acting SC insulin with first meal, then stop IV insulin 30 min after.
Continue/titrate basal insulin; provide sick-day rules and hypoglycaemia education before discharge.

12) Escalation (HDU/ICU criteria)

pH < 7.0 or HCO₃ < 5; ketones > 6; K⁺ < 3.5 despite replacement; SaO₂ < 92% on air; SBP < 90; GCS < 12; severe comorbidity (elderly, pregnancy, renal/cardiac).

Common Pitfalls (say these in the OSCE)

❌ Stopping long-acting insulin.
❌ Failing to replace potassium adequately.
❌ Not starting antibiotics within 1 hour when sepsis suspected.
❌ Forgetting ECG/troponin (silent MI) or lipase (pancreatitis).
❌ Fluid over-resuscitation in frail/cardiac/renal patients.

💡 Exam line to use: “I’ll manage DKA per the national protocol, and simultaneously implement the Sepsis Six if infection is suspected, screen for MI with ECG/troponin, check lipase for pancreatitis, and do a pregnancy test where appropriate.”

The content on this website is provided for educational and informational purposes only to support exam preparation (e.g., MLA, MRCP, USMLE) and learning. This is NOT medical advice, diagnosis, treatment, or professional guidance. It does not replace consultation with a qualified healthcare professional, official guidelines (e.g., NICE, GMC, BNF), or supervised clinical practice. Always verify information with current, authoritative sources. Makindo and its contributors accept no liability for any reliance on this content, including errors, omissions, or any resulting harm, loss, or consequences. By using this site, you agree to these terms.

Diabetic Ketoacidosis (DKA) Adults