Author: Dr. Trevor Landas

I’m not sure about y’all but I honestly have not seen too many pediatric DKA patients. I’m assuming it probably has to do with thorough screening, but it’s important to know how it is managed because it has a couple nuances that are different than the treatment of adult patients.

Definition and Diagnosis

  • Hyperglycemia (serum glucose > 200)
  • Anion Gap Metabolic Acidosis (pH <7.3)
  • Elevated Ketones, most notably B-hydroxybutyrate (urine or serum)

Diabetic Ketoacidosis is defined as the following triad: hyperglycemia, anion gap metabolic acidosis, and elevated ketones. It develops due to a deficiency of insulin and an increase in counter-regulatory hormones. It is important to note that in all diabetics, although medication non-compliance is often the precipitating factor, infectious etiologies are another common cause and must be factored into the workup in the emergency room.

Clinical Presentation

These patients are DRY! DRY! DRY! Due to hyperglycemia, there is a subsequent osmotic diuresis leading to profound dehydration. This leads to polydipsia and polyuria. With the diuresis, there are electrolyte imbalances that lead to abdominal cramping, nausea, and vomiting. In severe cases, neurological deficits and headache may be seen, and may indicate the most feared complication – cerebral edema.


  • Vitals
  • POC Glucose
  • Serum Ketones, Urine Ketones
  • VBG/pH
  • CBC
  • CMP + Mg + Phosphorus + iCal
  • EKG
  • New Dx include: C-peptide, Insulin level, Islet cell antibody panel
  • Infectious Workup as needed: CXR, UA + urine culture
  • Anion Gap –Use the serum Na, not the corrected Na*


Assess ABCs. Establish IV access.

“Fill the tank and close the gap.”

Cerebral Edema

The most feared complication. Extremely rare, occurring in <1% of patients with DKA, but it has an very high mortality. Have a very low threshold to treat. Discussion should be made with the PICU attending. Presents with neurological deficits, AMS, or severe headache.
– Mannitol 0.5 – 1 g/kg IV over 20 minutes
– Hypertonic Saline (3%) 5 – 10 cc/kg over 30 min




  • Long B, Koyfman A. Emergency Medicine Myths: Cerebral Edema in Pediatric Diabetic Ketoacidosis and Intravenous Fluids. J Emerg Med. 2017;53(2):212–221. doi:10.1016/j.jemermed.2017.03.014
  • Olivieri L, Chasm R. Diabetic ketoacidosis in the pediatric emergency department. Emerg Med Clin North Am. 2013;31(3):755–773. doi:10.1016/j.emc.2013.05.004

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