From the Guidelines
Pre-hospital treatment of diabetic ketoacidosis (DKA) should focus on stabilization and initial management with fluid resuscitation, oxygen therapy, and cardiac monitoring, without administering insulin, as this requires careful monitoring and laboratory values not typically available in the field. The primary interventions include establishing IV access with two large-bore catheters and initiating fluid resuscitation with normal saline (0.9% NaCl) at 15-20 mL/kg in the first hour (typically 1-2 liters for adults) 1. Oxygen should be administered to maintain SpO2 above 94%, and continuous cardiac monitoring should be established. Blood glucose should be measured immediately and monitored every 30 minutes. If hypoglycemia is present (rare in DKA), administer D50W 25g IV.
Some key points to consider in pre-hospital treatment of DKA include:
- Assessing for signs of hypovolemic shock and treating accordingly
- Obtaining a 12-lead ECG to evaluate for hyperkalemia (peaked T waves, widened QRS) which commonly accompanies DKA
- Monitoring for altered mental status and positioning the patient to protect the airway if consciousness is decreased
- The goal of pre-hospital care is to begin addressing the severe dehydration that occurs in DKA due to osmotic diuresis from hyperglycemia, while preparing for rapid transport to definitive care. According to the recent standards of care in diabetes-2025, fluid resuscitation helps improve tissue perfusion and begins to address the metabolic derangements, though complete resolution requires insulin therapy and electrolyte management that will be initiated in the hospital setting 1.
From the Research
Treatment of DKA in Pre-Hospital Setting
- The provided studies do not directly address the treatment of DKA in a pre-hospital setting, but rather focus on in-hospital management 2, 3, 4, 5, 6.
- However, some general principles of DKA management can be applied to pre-hospital care, such as the importance of fluid resuscitation and insulin therapy 2, 4.
- The choice of intravenous fluid for resuscitation is a topic of debate, with some studies suggesting that balanced solutions may be preferable to normal saline due to their potential to correct acidosis more quickly 5, 6.
- In the pre-hospital setting, the goal would be to initiate fluid resuscitation and insulin therapy as soon as possible, while also preparing the patient for transport to a hospital for further management.
Key Considerations for Pre-Hospital DKA Management
- Fluid resuscitation: consider using balanced solutions such as lactated Ringers instead of normal saline 5, 6.
- Insulin therapy: continuous IV insulin is recommended, but this may not be feasible in a pre-hospital setting 2, 4.
- Monitoring: keep track of the patient's vital signs, glucose levels, and electrolyte levels as much as possible in the pre-hospital setting 2, 4.
- Communication: ensure that the hospital is aware of the patient's condition and any treatment that has been initiated in the pre-hospital setting 2, 4.