Initial Emergency Assessment

Fig 6: Patients with DKA can be critically ill at presentation and should be managed systematically

Airway, breathing and circulation form part of the initial emergency management of paediatric DKA [22,25]:


  • Ensure patent
  • Consider adjuncts or definitive airway if indicated
  • Seek anaesthetic support if there are concerns
  • Due to the high risk of aspiration pneumonia an NG tube should be seriously considered in the following situations:
    • a child with reduced level of consciousness
    • and/or recurrent vomiting
    • & or recent consumption of a large volume of fruit juice or high sugar drinks[28-29]


  • Give 100% oxygen by non re-breathe mask


  • Obtain IV access
    • Ideally 2 points of access
    • Avoid central access due to increased risk of thrombus
  • Attach patient to a cardiac monitor[30,31]
    • Perform a 12 lead ECG, and evaluate for T wave changes, and assess for signs of shock
  • All patients should be given fluid replacement and this should occur before insulin/immediately. The amount of fluid is dependant on if they are shocked:
    • Shocked patients (heart rate, capillary refill time):
      • 20ml/kg of 0.9% (normal) saline over 15 minutes
      • If required, further 10ml/kg boluses up to a maximum of 40ml/kg at which point inotropes should be considered
      • Boluses for shocked patients should not be subtracted from the fluid deficit
    • Non-shocked patients
      • 10ml/kg bolus of 0.9% (normal) saline over 60 minutes
      • Do not give more than 10ml/kg without decision with the responsible consultant
      • Boluses for non-shocked patients should be subtracted from the fluid deficit
Fig 7: Resuscitation fluid

Confirm the diagnosis

Table1: Symptoms, signs & biochemical features of DKA

Initial investigations

  • Blood glucose
  • Laboratory U&Es, Osmolality, FBC, CRP, Albumin, Calcium, Phosphate and Magnesium
  • Venous blood gas
    • pH and PC02 are comparable to arterial samples
    • Blood gas electrolytes are useful in guiding early fluid management before laboratory results are available
  • Blood ketones
    • Near patient test similar to bedside glucose meters
    • Superior to urinary ketones as:
      • Rapid result
      • Quantitative rather than qualitative (mmol/L)
  • ECG

NB: Other investigations should only be performed if indicated (i.e. septic screen in patients who are febrile, CXR etc.)