![]() ![]() Assessing volume depletion can be difficult, with substantial inter-rater variability. ![]() Further evaluation should solicit history of precipitating factors (e.g., infection, intoxication) and medication adherence for individuals with known diabetes. ![]() Initial clinical assessment should include ABCDs and evaluation of tachypnea and altered breathing patterns, perfusion, fluid balance, and level of consciousness. Presenting symptoms of DKA may include polyuria, polydipsia, polyphagia, weakness, nausea, vomiting, abdominal pain, decreased level of consciousness, Kussmaul breathing, and acetone breath. DKA should be differentiated from hyperosmolar hyperglycemic state (HHS) which is characterized by more severe volume depletion and extreme electrolyte imbalances in the absence of significant ketosis and acidosis. Serum potassium may be normal or elevated due to extracellular shifts, but total body potassium is invariably low due to osmotic diuresis and active urinary excretion. Low insulin levels reduce glucose utilization, and subsequent cellular glycopenia triggers increased glucagon release, lipolysis, and oxidation of free fatty acids, with ensuing ketoacidosis. In DKA, hyperglycemia leads to urinary losses of both water and electrolytes, with resulting in volume depletion and metabolic disturbances.
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