Symptoms of Diabetic Ketoacidosis (DKA)
DKA typically presents with polyuria, polydipsia, weight loss, nausea, vomiting, abdominal pain, dehydration, and Kussmaul respirations (deep, rapid breathing), developing over hours to days. 1
Cardinal Symptoms
The classic presentation includes:
Polyuria (excessive urination), polydipsia (excessive thirst), and weight loss are the most common initial symptoms, occurring as the body attempts to eliminate excess glucose through the kidneys 2, 1, 3
Nausea and vomiting are present in many patients and can be severe enough to mimic an acute abdomen, with up to 25% of patients experiencing emesis that may be coffee-ground in appearance 2, 1
Abdominal pain occurs frequently in DKA (but not in HHS), which can mislead clinicians toward surgical diagnoses 2, 1
Dehydration manifests as poor skin turgor and is a common physical finding due to osmotic diuresis from hyperglycemia 2, 1
Respiratory and Metabolic Signs
Kussmaul respirations (deep, rapid breathing) are characteristic of DKA and represent the body's respiratory compensation for metabolic acidosis 2, 1
Fruity breath odor from acetone is a hallmark sign that helps confirm ketosis 4, 5
Dyspnea or shortness of breath may be reported as the acidosis worsens 3
Cardiovascular and Neurological Manifestations
Tachycardia and hypotension develop from severe dehydration and volume depletion 2, 4
Altered mental status ranging from drowsiness and lethargy to confusion, with patients typically more alert in DKA than in HHS, though consciousness can deteriorate as the condition worsens 2, 1, 4
Flushed face is commonly observed 5
Coma can occur in severe cases, though this is more frequent in HHS than DKA 2
Systemic Symptoms
Severe fatigue and weakness are reported as the metabolic derangements progress 2, 3
Loss of appetite typically accompanies the gastrointestinal symptoms 5
Hypothermia or normothermia may be present even when infection is the precipitating factor; hypothermia is a poor prognostic sign 2
Timeline and Evolution
DKA develops rapidly over hours to 24 hours in most cases, though symptoms of poorly controlled diabetes may be present for several days beforehand 2, 1
Occasionally, the entire presentation can evolve acutely with no prior warning symptoms 2
Critical Warning Signs Requiring Immediate Medical Attention
Inability to tolerate oral hydration 1
Blood glucose levels that do not improve with insulin administration 1
Any signs of altered mental status or worsening illness 1
Presence of ketones in blood or urine with hyperglycemia and vomiting 6, 4
Special Consideration: Euglycemic DKA
Approximately 10% of DKA cases present with blood glucose <200 mg/dL (euglycemic DKA), particularly in pregnancy, with SGLT2 inhibitor use, reduced food intake, alcohol use, or liver failure 1, 4
This variant can be easily missed if clinicians rely solely on hyperglycemia for diagnosis 1
Common Pitfall
Never dismiss DKA based on normal or mildly elevated glucose levels alone—always check for ketones and metabolic acidosis when patients present with nausea, vomiting, and abdominal pain, especially if they have diabetes or are taking SGLT2 inhibitors 1, 4