What is the treatment for a patient in diabetic ketoacidosis (DKA) in an urgent care setting and should they be referred to the emergency room (ER)?

Management of Diabetic Ketoacidosis in Urgent Care and Referral to Emergency Room

A patient with diabetic ketoacidosis (DKA) should be immediately referred to the emergency room as urgent care facilities are not equipped to provide the intensive monitoring and treatment required for this life-threatening condition. 1, 2

Initial Assessment in Urgent Care

• Perform rapid clinical assessment to confirm suspicion of DKA by checking for:

  • Hyperglycemia (though not always present in euglycemic DKA)
  • Metabolic acidosis (pH <7.3, serum bicarbonate <18 mEq/L)
  • Elevated serum ketones 1, 3

• Check for signs of severe DKA requiring immediate transfer:

  • Altered mental status
  • Severe dehydration
  • Hypotension
  • Severe acidosis (pH <7.0)
  • Significant electrolyte abnormalities 2, 3

Initial Stabilization Measures While Arranging Transfer

• Begin fluid resuscitation with isotonic saline (0.9% NaCl) at 15-20 mL/kg/hour during the first hour to restore circulatory volume while arranging emergency transport 1, 2

• Monitor vital signs continuously, with particular attention to cardiac rhythm, as electrolyte imbalances can trigger arrhythmias 4

• If glucose is severely elevated (>250 mg/dL), consider administering a single dose of rapid-acting insulin (0.1 units/kg) subcutaneously while arranging transfer 1, 5

• Do not delay transfer to the emergency department for laboratory results beyond point-of-care glucose, if DKA is clinically suspected 1, 2

Rationale for Emergency Room Referral

• DKA requires intensive monitoring and treatment that cannot be adequately provided in an urgent care setting:

  • Continuous cardiac monitoring for arrhythmias 4
  • Frequent laboratory monitoring (every 2-4 hours) of electrolytes, glucose, blood urea nitrogen, creatinine, and osmolality 2
  • Intravenous insulin administration and titration 1, 2
  • Aggressive fluid resuscitation and electrolyte replacement 1, 2

• Successful management requires resources typically only available in hospital settings:

  • The American Diabetes Association recommends continuous intravenous insulin as the standard of care for critically ill patients with DKA 2
  • Careful potassium replacement and monitoring is essential, as total body potassium deficits are common despite potentially normal or elevated initial serum levels 2
  • Treatment of underlying precipitating causes often requires hospital-level diagnostics and interventions 1, 2

Common Pitfalls to Avoid

• Do not delay transfer to attempt complete management in the urgent care setting, as this increases risk of complications 2

• Avoid administering bicarbonate, as studies have shown it makes no difference in resolution of acidosis and is generally not recommended 1, 2

• Do not withhold initial fluid resuscitation while awaiting transfer, as inadequate fluid resuscitation can delay recovery and worsen outcomes 2

• Be aware that patients on SGLT2 inhibitors can develop euglycemic DKA (normal or only slightly elevated glucose levels with ketoacidosis), which may be missed if only relying on hyperglycemia for diagnosis 6

Key Points for Communication with Emergency Department

• Provide clear documentation of:

  • Initial assessment findings
  • Interventions performed in urgent care
  • Timing of last insulin dose if patient is on insulin
  • Potential precipitating factors identified (infection, medication non-compliance, etc.) 1, 3
  • Any medications that may contribute to DKA (e.g., SGLT2 inhibitors) 6

• Ensure continuity of care by direct communication with receiving emergency department physician 2