Name: DKA / hyperglycemia — bulletproof documentation — ER Toolkit
Creator: Kim Trinh, MD

DKA care is a sequence with a few non-negotiables: confirm the triad, check potassium before insulin, hunt the precipitant, and — in children — watch for cerebral edema. The defensible chart documents that order and the reasoning, because the dangerous errors here are procedural.

01What's at stake

Hyperglycemia alone is not DKA — DKA requires an anion-gap metabolic acidosis with ketosis. The lethal pediatric complication is cerebral edema (rare, but the cause of most DKA deaths), and the classic procedural misses are giving insulin before knowing the potassium, decreasing insulin for a falling glucose instead of adding dextrose, and missing the precipitant.

02Diagnosis & the precipitant

The triad: hyperglycemia + anion-gap metabolic acidosis + ketosis/ketonemia (β-hydroxybutyrate). Hyperglycemia without acidosis is not DKA. → confirm all three
HHS — marked hyperglycemia/hyperosmolality without significant ketoacidosis.
Search the precipitant: infection, insulin omission/pump failure, new-onset diabetes, ACS, pregnancy, drugs (and euglycemic DKA with SGLT2 inhibitors). → treat the cause
Type 2 diabetes does not exclude DKA (ketosis-prone).

03The can't-miss complication — cerebral edema

Mostly pediatric; rare but accounts for most DKA deaths. Watch for headache, altered/fluctuating mental status, bradycardia, hypertension, vomiting. → treat clinically
Risk factors: younger age, new-onset, severe acidosis, bicarbonate use, over-rapid fluids, insulin in the first hour.
It's a clinical diagnosis — treat (reduce fluid rate, mannitol or hypertonic saline) before/without waiting for CT (up to 40% of scans are normal early).

Skip the typing

Work the case in the Hyperglycemia / DKA Workup — it records ketones/anion gap, the precipitant search, and the ECG, and assembles an MDM that documents the triad, the potassium-before-insulin sequence, and the cerebral-edema watch.

04Management sequence

Fluids first — isotonic resuscitation (cautious/weight-based in children; avoid over-resuscitating a merely tachycardic child).
Potassium before/with insulin — insulin and acidosis correction drive K⁺ into cells; replete once K⁺ is known and urine output established, and don't start insulin if K⁺ is low. Recheck K⁺ frequently.
Insulin infusion (no bolus in children) after fluids/potassium; never stop the drip for a falling glucose — add dextrose when glucose reaches ~200–250 mg/dL to keep the infusion going and shut off ketogenesis.
Avoid bicarbonate (reserve for extreme acidosis); treat the precipitant.
Resolution = closing the anion gap, not a normal glucose; monitor and transition off the infusion with overlap.

05What to document

▼ weak

"Glucose 600, started insulin drip and fluids. Glucose dropping, turned insulin down."

▲ defensible

"Glucose 540, venous pH 7.18, anion gap 24, ketones positive — DKA confirmed (triad). Precipitant sought: infection workup, insulin adherence reviewed. Isotonic fluids started; potassium 3.6 with urine output — repleted, insulin infusion started after K⁺ known (no bolus). Dextrose added at glucose ~250 with insulin continued. Bicarbonate withheld. Serial neuro checks for cerebral-edema signs. Resolution tracked by closing anion gap; admitted with endocrine involvement."

06Where charts fail

Calling hyperglycemia without acidosis "DKA," or missing the precipitant (infection, ACS, euglycemic SGLT2 DKA).
Starting insulin before knowing potassium (or with hypokalemia).
Decreasing the insulin infusion for a falling glucose instead of adding dextrose.
Giving bicarbonate routinely.
In children: not watching for cerebral edema, or over-resuscitating with fluids.

07Sources

Bonadio W. Pediatric diabetic ketoacidosis: an outpatient perspective on evaluation and management. Pediatric Emergency Medicine Practice (EB Medicine). 2013;10(3).
Wolfsdorf J, Glaser N, Sperling MA. Diabetic ketoacidosis in infants, children, and adolescents: an ADA consensus statement. Diabetes Care. 2006;29(5):1150-1159.
Glaser N, Barnett P, McCaslin I, et al. Risk factors for cerebral edema in children with diabetic ketoacidosis. N Engl J Med. 2001;344(4):264-269.
Kitabchi AE, Umpierrez GE, Miles JM, et al. Hyperglycemic crises in adult patients with diabetes. Diabetes Care. 2009;32(7):1335-1343.

Note: the EB source is a pediatric DKA review; the no-bolus rule, conservative fluids, and cerebral-edema emphasis are peds-specific — apply adult protocols (e.g., Kitabchi/ADA) for adults and follow local protocol.

DKA & hyperglycemia: documentation that holds up