What is the best way to manage diabetic ketoacidosis while awaiting emergency services?

Pre-Hospital Management of Diabetic Ketoacidosis

Call emergency services (9-1-1) immediately and do not attempt to treat DKA in the field—this is a life-threatening emergency requiring hospital-based intensive care with intravenous fluids, insulin infusion, and continuous laboratory monitoring. 1, 2, 3

Immediate Actions While Awaiting Ambulance

Primary Response

• Position the patient safely: If conscious, keep them sitting upright or in a comfortable position; if unconscious or vomiting, place in recovery position to protect the airway 1
• Do not give insulin: Pre-hospital insulin administration without IV fluids, electrolyte monitoring, and laboratory support is dangerous and can precipitate life-threatening hypokalemia 1, 4
• Do not give oral fluids if altered mental status: Only offer small sips of water if the patient is fully conscious, able to follow commands, and can swallow safely 1

Critical Monitoring

• Assess level of consciousness: Note any confusion, lethargy, or deterioration in mental status, as this correlates with severity of hyperosmolarity 1, 2
• Monitor breathing pattern: DKA patients often have deep, rapid breathing (Kussmaul respirations) as the body attempts to compensate for metabolic acidosis 3, 5
• Watch for vomiting: This increases dehydration risk and aspiration potential 2, 5

What NOT to Do (Critical Pitfalls)

• Never administer subcutaneous or intramuscular insulin: DKA requires IV insulin therapy with concurrent aggressive fluid resuscitation—insulin without fluids worsens dehydration and can cause cardiovascular collapse 4, 5
• Never give oral glucose or sugary drinks: Unlike hypoglycemia, DKA involves severely elevated blood glucose; adding more sugar is harmful 1
• Never delay calling emergency services: DKA mortality ranges from 2-5% in developed countries and up to 24% in resource-limited settings when improperly managed 2, 5
• Do not attempt oral rehydration in confused patients: Risk of aspiration outweighs any benefit 1

Information to Provide to EMS

When emergency services arrive, relay:

• Diabetes history: Type 1 or type 2, usual insulin regimen, recent medication adherence 5
• Precipitating factors: Recent illness, infection, missed insulin doses, new medications (especially SGLT2 inhibitors) 5
• Symptom timeline: When symptoms began, progression of confusion or vomiting 2, 3
• Recent blood glucose readings: If available from home monitoring 3

Why Hospital Treatment is Essential

DKA requires hospital-based management that cannot be replicated pre-hospital:

• Aggressive IV fluid resuscitation: 15-20 mL/kg/hour initially to restore circulating volume, with total deficits of 9 liters requiring 24-hour correction 4
• Continuous IV insulin infusion: 0.1 units/kg/hour with hourly glucose monitoring and dose adjustments 1, 4
• Electrolyte replacement: Potassium must be monitored and replaced (20-40 mEq/L) as insulin drives it intracellularly, risking fatal cardiac arrhythmias 4, 5
• Laboratory monitoring every 2-4 hours: Glucose, electrolytes, pH, osmolality, and ketones guide therapy adjustments 4, 3
• ICU-level care: Severe cases with ketonemia ≥1.5 mmol/L require intensive care unit admission 1, 4

The single most important pre-hospital intervention is rapid transport to emergency care—any delay or attempt at field treatment increases mortality risk. 2, 3, 5