Diabetic Keto Acid-OH-SHIT

When the body runs out of insulin and immediately makes it everyone’s problem.

This week on the podcast, we're talking about Diabetic Ketoacidosis, better known as DKA, or as we prefer to call it:

Diabetic Keto Acid-OH-SHIT.

Because few things say “this shift was going suspiciously well” quite like a profoundly dehydrated diabetic patient breathing 36 times a minute with a glucose reading that makes your glucometer reconsider its career choices.

So, what the hell is DKA?

Glad you asked!

DKA happens when there isn't enough effective insulin available for glucose to get where it needs to go.

And the catch it that the glucose is there.

Ohhhh, there's glucose.

There's glucose fucking everywhere. The patient is literally pissing it away.

The problem is that without enough insulin, much of that glucose can't effectively enter insulin-dependent cells. So despite having a bloodstream resembling maple syrup, the body interprets the situation as:

“WE ARE STARVING.”

The body responds by breaking down fat for energy.

Fat breakdown produces ketones. Mother fucking ketones!

Ketones are acidic, like the blood of a Xenomorph.

Ketones accumulate...Xenomorphs everywhere.

The pH drops....The patient is becomming a Xenomorph!

And congratulations, everybody. We've turned a metabolic problem into a full-blown acid-base dumpster fire. Lets Fucking GO!!!

Enter: Kussmaul respirations

As metabolic acidosis develops, the body does something remarkably clever.

It tries to fix the problem (its about damn time, too!)

Since carbon dioxide contributes to the body's acid load, the respiratory system starts dumping CO₂ like somebody just yelled:

“THE COPS ARE COMING!”

The result is Kussmaul respirations: deep, rapid breathing intended to compensate for the metabolic acidosis.

And this is where DKA patients can get particularly interesting for paramedics.

Because that respiratory rate isn't necessarily the problem.

It's part of the solution.

Your patient breathing 35 or 40 times per minute may be generating an enormous minute ventilation specifically to keep their pH from falling even further.

Which means if that patient becomes exhausted, loses consciousness, and requires assisted ventilation, casually deciding that 10 breaths per minute sounds reasonable can be a very bad idea.

Their respiratory rate isn't just a number.

It's metabolic life support.

Meanwhile, the kidneys are having an absolutely terrible day.

Remember all that glucose floating around?

Eventually, the kidneys start dumping glucose into the urine.

Water follows.

So now your patient is urinating excessively, losing fluid and electrolytes, getting progressively dehydrated, and wondering why standing up suddenly feels like trying to operate a human body with four AA batteries.

This contributes to the classic DKA presentation:

Polyuria. Polydipsia. Dehydration. Tachycardia. Weakness. Nausea. Vomiting. Abdominal pain. Altered LOC.

And, of course:

Kussmaul respirations.

You may also encounter the famous fruity or acetone-like breath associated with ketone production.

Nothing says medical emergency quite like leaning toward your patient and thinking:

“Why does Gerald smell like nail-polish remover?”

But the glucose isn't the whole story.

One of the biggest traps with DKA is seeing the high blood glucose and thinking:

“Ah yes. Sugar problem.”

Not exactly.

DKA is a metabolic catastrophe involving insulin deficiency, ketone production, acidosis, dehydration, and major electrolyte shifts.

And potassium deserves special mention.

Serum potassium can initially appear normal or elevated even though the patient's total-body potassium is depleted.

Then treatment begins.

Insulin starts pushing potassium back into cells.

And suddenly potassium can drop dramatically.

Which is why potassium in DKA is less of a laboratory value and more of a tiny electrolyte holding a knife behind its back.

So what are we doing about it?

Prehospital priorities depend on your scope and local protocols, but generally we're thinking about:

Airway. Breathing. Circulation. Glucose. Hydration. Cardiac monitoring. Transport.

IV access is important.

Fluid resuscitation may be important.

Monitoring is important.

Identifying the underlying trigger is important.

And remembering that DKA is not fixed by simply making the glucose number prettier is extremely important.

Infection, missed insulin, pump failure, newly diagnosed diabetes, myocardial infarction, medications, physiologic stress, and other illnesses can all trigger DKA.

So when you're assessing these patients, don't stop at:

“Are you diabetic?”

Find out what changed.

And then there's the airway...

This is where things can get spicy.

A severely acidotic DKA patient may be maintaining their pH through an extraordinarily high minute ventilation.

If they require intubation, removing that spontaneous respiratory compensation, even briefly, can be dangerous.

After intubation, ventilation needs to account for the very high pre-intubation ventilatory demand while avoiding other harms from excessive ventilation.

In other words:

Your ventilator doesn't give a shit that the textbook default rate looks nice.

Your patient's physiology does.

This is one of the reasons airway management in profound metabolic acidosis deserves serious respect.

This week's episode

In Diabetic Keto Acid-OH-SHIT, we're getting into:

• What DKA actually is

• Why insulin deficiency causes ketone production

• Why these patients become so profoundly dehydrated

• What the hell potassium is doing

• Why Kussmaul respirations are actually helping

• Why ventilation strategy matters when the patient deteriorates

• What paramedics should be looking for

• How DKA is approached in the Alberta EMS environment

• And why your glucometer saying “HI” is considerably less friendly than it sounds

As always, this podcast is educational.

It is not medical direction.

I am not your medical director.

And if you start treating patients based exclusively on something you heard while driving to work listening to two paramedics make inappropriate jokes about metabolic acidosis, your actual medical director may wish to have a fucking word with you.

Check your protocols.

Know your scope.

Understand the physiology.

And most importantly:

Don't fuck with the Kussmauls.

That Paramedic Podcast

This week: Diabetic Keto Acid-OH-SHIT.

Come for the ketones. Stay for the catastrophic electrolyte abnormalities.

Written by J. Davis