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Episode 894: DKA and HHS

Emergency Medical Minute

Release Date: 03/11/2024

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Contributor: Ricky Dhaliwal, MD

Educational Pearls:

What are DKA and HHS?

  • DKA (Diabetic Ketoacidosis) and HHS (Hyperosmolar Hyperglycemic State) are both acute hyperglycemic states.


  • More common in type 1 diabetes.

  • Triggered by decreased circulating insulin.

    • The body needs energy but cannot use glucose because it can’t get it into the cells.

    • This leads to increased metabolism of free fatty acids and the increased production of ketones.

    • The buildup of ketones causes acidosis.

    • The kidneys attempt to compensate for the acidosis by increasing diuresis.

  • These patients present as dry and altered, with sweet-smelling breath and Kussmaul (fast and deep) respirations.


  • More common in type 2 diabetes.

  • In this condition there is still enough circulating insulin to avoid the breakdown of fats for energy but not enough insulin to prevent hyperglycemia.

  • Serum glucose levels are very high – around 600 to 1200 mg/dl.

  • Also presents similarly to DKA with the patient being dry and altered.

Important labs to monitor

  • Serum glucose

  • Potassium

  • Phosphorus

  • Magnesium

  • Anion gap (Na - Cl - HCO3)

  • Renal function (Creatinine and BUN)

  • ABG/VBG for pH

  • Urinalysis and urine ketones by dipstick


  • Identify the cause, i.e. Has the patient stopped taking their insulin?

  • Aggressive hydration with isotonic fluids.

    • Normal Saline (NS) vs Lactated Ringers (LR)?

      • LR might resolve the DKA/HHS faster with less risk of hypernatremia.

  • Should you bolus with insulin?

  • No, just start a drip.

    • 0.1-0.14 units per kg of insulin.

  • Make sure you have your potassium back before starting insulin as the insulin can shift the potassium into the cells and lead to dangerous hypokalemia.

  • Should you treat hyponatremia?

    • Make sure to correct for hyperglycemia before treating. This artificially depresses the sodium.

  • Should you give bicarb?

    • Replace if the pH < 6.9. Otherwise, it won’t do anything to help.

  • Don’t intubate, if the patient is breathing fast it is because they are compensating for their acidosis.


  1. Andrade-Castellanos, C. A., Colunga-Lozano, L. E., Delgado-Figueroa, N., & Gonzalez-Padilla, D. A. (2016). Subcutaneous rapid-acting insulin analogues for diabetic ketoacidosis. The Cochrane database of systematic reviews, 2016(1), CD011281. https://doi.org/10.1002/14651858.CD011281.pub2

  2. Chaithongdi, N., Subauste, J. S., Koch, C. A., & Geraci, S. A. (2011). Diagnosis and management of hyperglycemic emergencies. Hormones (Athens, Greece), 10(4), 250–260. https://doi.org/10.14310/horm.2002.1316

  3. Dhatariya, K. K., Glaser, N. S., Codner, E., & Umpierrez, G. E. (2020). Diabetic ketoacidosis. Nature reviews. Disease primers, 6(1), 40. https://doi.org/10.1038/s41572-020-0165-1

  4. Duhon, B., Attridge, R. L., Franco-Martinez, A. C., Maxwell, P. R., & Hughes, D. W. (2013). Intravenous sodium bicarbonate therapy in severely acidotic diabetic ketoacidosis. The Annals of pharmacotherapy, 47(7-8), 970–975. https://doi.org/10.1345/aph.1S014

  5. Modi, A., Agrawal, A., & Morgan, F. (2017). Euglycemic Diabetic Ketoacidosis: A Review. Current diabetes reviews, 13(3), 315–321. https://doi.org/10.2174/1573399812666160421121307

  6. Self, W. H., Evans, C. S., Jenkins, C. A., Brown, R. M., Casey, J. D., Collins, S. P., Coston, T. D., Felbinger, M., Flemmons, L. N., Hellervik, S. M., Lindsell, C. J., Liu, D., McCoin, N. S., Niswender, K. D., Slovis, C. M., Stollings, J. L., Wang, L., Rice, T. W., Semler, M. W., & Pragmatic Critical Care Research Group (2020). Clinical Effects of Balanced Crystalloids vs Saline in Adults With Diabetic Ketoacidosis: A Subgroup Analysis of Cluster Randomized Clinical Trials. JAMA network open, 3(11), e2024596. https://doi.org/10.1001/jamanetworkopen.2020.24596

Summarized by Jeffrey Olson MS2 | Edited by Meg Joyce & Jorge Chalit, OMSII