Signs and Symptoms of Diabetic Ketoacidosis (DKA)
Diabetic ketoacidosis presents with a characteristic pattern of symptoms including polyuria, polydipsia, polyphagia, weight loss, vomiting, abdominal pain, dehydration, weakness, clouding of sensoria, and in severe cases, coma. 1
Clinical Presentation
Cardinal Symptoms
- Polyuria (excessive urination)
- Polydipsia (excessive thirst)
- Polyphagia (excessive hunger)
- Weight loss
- Dehydration with poor skin turgor
Gastrointestinal Symptoms
- Nausea and vomiting (occurs in up to 25% of DKA patients) 1
- Abdominal pain (characteristic of DKA but not HHS) 1
- Coffee-ground emesis may be present and guaiac positive (related to hemorrhagic gastritis) 1
Respiratory Findings
- Kussmaul respirations (deep, rapid breathing) - distinctive sign of DKA 1
- Fruity breath odor (due to acetone) 2
Neurological Manifestations
- Mental status changes ranging from full alertness to profound lethargy 1
- Clouding of sensoria progressing to coma in severe cases 1
- Stupor/coma in severe DKA (pH <7.00) 3
Cardiovascular Signs
- Tachycardia
- Hypotension
- Signs of shock in advanced cases 1
Laboratory Findings
DKA is diagnosed based on the following criteria:
- Blood glucose >250 mg/dL (though euglycemic DKA can occur) 4
- Arterial pH <7.3 or serum bicarbonate <15 mEq/L 1
- Moderate ketonemia or ketonuria 4
Severity Classification
| Parameter | Mild | Moderate | Severe |
|---|---|---|---|
| Arterial pH | 7.25-7.30 | 7.00-7.24 | <7.00 |
| Bicarbonate (mEq/L) | 15-18 | 10-14 | <10 |
| Mental Status | Alert | Alert/drowsy | Stupor/coma |
Timing of Symptom Development
DKA typically develops more rapidly than hyperosmolar hyperglycemic state (HHS):
Risk Factors and Precipitating Factors
Common Precipitating Factors
- Infection (most common, occurring in 30-50% of cases) 5
- Discontinuation or inadequate insulin in established type 1 diabetes 1
- New-onset type 1 diabetes 1
- Medications affecting carbohydrate metabolism (corticosteroids, thiazides, sympathomimetic agents) 1
- Acute medical events (cerebrovascular accident, alcohol abuse, pancreatitis, myocardial infarction, trauma) 1
- Psychological stress and eating disorders (in up to 20% of recurrent DKA cases in young patients) 1
Warning Signs Requiring Immediate Medical Attention
Patients should seek immediate medical attention if they experience:
- Blood glucose >350 mg/dL with symptoms of metabolic decompensation 3
- Inability to tolerate oral hydration 1
- Blood glucose levels not improving with insulin administration 1
- Altered mental status 1
- Signs of worsening illness 1
Important Considerations
- Patients may be normothermic or even hypothermic despite infection due to peripheral vasodilation 1
- Hypothermia is a poor prognostic sign 1
- DKA can occur in both type 1 and type 2 diabetes, though it's more common in type 1 5
- One-third of hyperglycemic emergencies have a hybrid DKA-HHS presentation 1
- Patients at risk for DKA should measure urine or blood ketones when glucose levels exceed 200 mg/dL, especially during illness or after missed insulin doses 1
Early recognition of these signs and symptoms is crucial for prompt treatment and prevention of life-threatening complications of DKA, which has a mortality rate of approximately 5% in experienced centers 1.