Diabetic Ketoacidosis (DKA)
A patient presenting with nausea and a soapy or nail-polish-remover odor most likely has diabetic ketoacidosis (DKA), which is a life-threatening emergency requiring immediate evaluation and treatment. 1
Why This Diagnosis
The soapy or nail-polish-remover smell is acetone breath, which is pathognomonic for ketosis and specifically indicates DKA rather than simple hyperglycemia or other metabolic derangements. 1 When combined with nausea and vomiting, this presentation strongly suggests DKA and warrants urgent intervention. 2, 1
Immediate Diagnostic Workup
Obtain the following tests immediately upon presentation:
- Arterial blood gas to assess pH (DKA defined as pH <7.3) 1
- Serum ketones (beta-hydroxybutyrate preferred) or urine ketones 1
- Complete metabolic panel including glucose, electrolytes, BUN, creatinine 1
- Anion gap calculation (DKA defined as anion gap >10 mEq/L) 1
The American Diabetes Association diagnostic criteria for DKA require: plasma glucose >250 mg/dL, arterial pH <7.3, serum bicarbonate <18 mEq/L, positive serum or urine ketones, and anion gap >10 mEq/L. 1
Critical Diagnostic Caveat
Be aware that approximately 10% of DKA cases present as euglycemic DKA with glucose <200 mg/dL, which can occur with reduced food intake, vomiting, pregnancy, alcohol use, or SGLT2 inhibitor medications. 1, 3, 4 Do not rule out DKA based on normal or near-normal glucose alone—the acetone breath and ketosis are the key diagnostic features. 1, 5
Immediate Management Protocol
Once DKA is confirmed, initiate the following treatment immediately:
Fluid Resuscitation
- Administer isotonic saline (0.9% NaCl) at 15-20 mL/kg/hour for initial volume resuscitation 1
Insulin Therapy
- Start continuous intravenous insulin infusion once DKA is confirmed 1
- Never discontinue insulin even if the patient cannot eat 1
Monitoring
- Monitor blood glucose every 1-2 hours 1
- Check electrolytes frequently (particularly potassium, which can drop precipitously with insulin therapy) 1
Differential Considerations
While DKA is the most likely diagnosis given the acetone odor, briefly consider:
- Acetone ingestion (fingernail polish remover) can present with similar odor, CNS depression, hyperglycemia, and ketosis, but history of ingestion is usually evident 5
- Alcoholic ketoacidosis can occur with excessive alcohol use and presents with ketosis, but typically has lower or normal glucose levels 6
The presence of nausea with acetone breath in a patient without clear toxic ingestion history makes DKA the primary diagnosis requiring immediate action. 1