Warning: DKA Can Kill in 24 Hours - Recognize These Diabetic Ketoacidosis Signs

🔬 What is Diabetic Ketoacidosis?

To understand DKA, you need to understand what happens when insulin is absent or severely insufficient.

The Normal Process

Under normal circumstances:

1. You eat food, which breaks down into glucose
2. Glucose enters your bloodstream
3. Your pancreas releases insulin
4. Insulin acts as a "key" that unlocks cells to let glucose in
5. Cells use glucose for energy

What Happens in DKA

When there's not enough insulin:

1. Glucose can't enter cells—it builds up in blood (hyperglycemia)
2. Cells are "starving" despite high blood glucose
3. Body switches to burning fat for energy (ketogenesis)
4. Fat breakdown produces ketones (acetone, acetoacetate, beta-hydroxybutyrate)
5. Ketones accumulate faster than the body can eliminate them
6. Blood becomes acidic (metabolic acidosis)
7. Acidosis disrupts heart, brain, and other vital organ function

Additionally, high blood glucose causes osmotic diuresis—your kidneys try to eliminate excess glucose through urine, taking water and electrolytes with it. This leads to severe dehydration, which worsens the acidosis in a dangerous cycle.

This is exactly what was happening inside Ananya's body that night. But what made her case particularly dangerous—and what trips up thousands of people every year—was how fast it escalated. The warning signs she missed could have given her hours of lead time.

The Three Hallmarks of DKA

⚠️ Warning Signs of Diabetic Ketoacidosis (DKA)

DKA symptoms typically develop over 24 hours but can progress faster during illness or pump failure. Recognizing early signs allows intervention before DKA becomes severe.

Early Warning Signs (Intervene at This Stage)

• High blood glucose: Readings consistently >250 mg/dL
• Positive ketones: Urine or blood ketone test shows presence of ketones
• Increased thirst: Extreme, unquenchable thirst
• Frequent urination: Much more than usual
• Fatigue: Unusual tiredness despite rest

Progressive Symptoms (Requires Urgent Medical Attention)

• Nausea and vomiting: Can't keep food or fluids down
• Abdominal pain: Often mistaken for stomach flu
• Fruity breath odor: Smells like nail polish remover or fruit—a classic DKA sign
• Kussmaul breathing: Deep, rapid, labored breathing—body trying to blow off acid
• Dehydration signs: Dry mouth, decreased skin turgor, dizziness when standing

Severe Symptoms (EMERGENCY - Call 911)

• Confusion: Difficulty thinking, answering questions, or staying focused
• Lethargy: Extreme drowsiness, difficulty staying awake
• Decreased consciousness: Responding slowly or not at all
• Coma: Unresponsive to stimulation

That fruity breath? That's exactly what Vikram noticed. Ananya had been vomiting and assumed it was food poisoning. But when he leaned in to help her up, that distinctive sweet-chemical smell hit him. He'd read about it years ago and never forgotten it. That single piece of knowledge got her to the ER 2 hours earlier than she would have gone otherwise—and her doctors later told her those 2 hours probably saved her life.

But what causes this cascade in the first place? The triggers might surprise you...

🎯 What Causes DKA?

DKA occurs when there's insufficient insulin. Understanding triggers helps with prevention.

Common DKA Triggers

Euglycemic DKA: A Special Case

In some cases, DKA can occur with blood glucose below 250 mg/dL—called euglycemic DKA. This is more common with:

• SGLT2 inhibitors: Medications like empagliflozin (Jardiance), dapagliflozin (Farxiga), canagliflozin (Invokana)
• Pregnancy: Increased glucose utilization can mask hyperglycemia
• Starvation/fasting: Low carbohydrate intake

Important: If you're on an SGLT2 inhibitor and feel unwell with nausea or vomiting, check ketones even if blood glucose isn't very high.

In Ananya's case, the trigger was deceptively simple: a 48-hour stomach bug. She couldn't keep food down, so she figured she didn't need her usual insulin. What she didn't realize is that illness actually increases insulin needs, even when you're not eating. By the time the vomiting "felt normal," her body had already started the ketone cascade.

So who's most at risk for this dangerous miscalculation? The answer reveals a pattern that could save your life...

👥 Who is at Risk for DKA?

Higher Risk Groups

• People with Type 1 diabetes: Dependent on external insulin; most common group for DKA
• Adolescents and young adults: May skip insulin or have inconsistent management
• People with eating disorders: May restrict insulin for weight control ("diabulimia")
• Those with poor healthcare access: Can't afford insulin or supplies
• Insulin pump users: If pump fails, no long-acting insulin backup
• People with psychiatric conditions: May have difficulty with consistent management
• Previous DKA history: Higher risk of recurrence

Type 2 Diabetes and DKA

While DKA is classically associated with Type 1 diabetes, Type 2 diabetics can also develop DKA:

• Ketosis-prone Type 2: More common in African American, Hispanic, and Asian populations
• During severe illness: Infection, surgery, major stress
• With SGLT2 inhibitors: Risk of euglycemic DKA
• When insulin-dependent: Type 2 diabetics on insulin can develop DKA if they miss doses

🚑 Emergency Response: What to Do

Step-by-Step Response

If blood glucose is >250 mg/dL:

1. Check ketones immediately (blood ketone meter preferred, urine strips as backup)
2. If ketones are negative/trace:
   • Give correction insulin according to your plan
   • Drink plenty of water
   • Recheck glucose in 2-4 hours
3. If ketones are small/moderate (0.6-1.5 mmol/L blood, or small-moderate urine):
   • Give extra insulin (typically 10-20% of total daily dose, per your sick day plan)
   • Drink 8 oz fluid per hour (water, broth, sugar-free beverages)
   • Recheck glucose and ketones every 2-4 hours
   • Contact your diabetes team if not improving
4. If ketones are large (>1.5 mmol/L blood, or large urine):
   • This is an emergency—seek medical care immediately
   • While waiting, give insulin if you can
   • Try to drink fluids if possible

When to Go to Emergency Room

Seek emergency care if:

• Blood glucose >300 mg/dL that doesn't respond to insulin
• Moderate or large ketones
• Vomiting and can't keep fluids down for >4 hours
• Signs of dehydration (dizziness, decreased urination, dry mouth)
• Fruity breath odor
• Rapid, deep breathing
• Confusion or altered mental state
• Abdominal pain with nausea

What NOT to Do

• Don't wait and see: DKA can progress rapidly
• Don't exercise: Exercise with high ketones can worsen DKA
• Don't skip insulin: Even if you're not eating, you need insulin
• Don't try to "flush out" ketones with excessive water alone: You need insulin to stop ketone production

🏥 Hospital Treatment for DKA

Understanding hospital treatment can reduce anxiety if you or a loved one needs emergency care.

Initial Assessment

Upon arrival, the medical team will:

• Check vital signs (blood pressure, heart rate, respiratory rate)
• Draw blood for glucose, ketones, electrolytes, pH (blood gas), kidney function
• Start IV access
• Assess consciousness level
• Look for underlying causes (infection, heart attack, etc.)

The Three Pillars of DKA Treatment

1. Fluid Resuscitation

Patients with DKA are typically 3-6 liters dehydrated. Treatment involves:

• Initial rapid IV fluids (usually normal saline)
• Slower maintenance fluids once initial deficit corrected
• Fluid choice may change as treatment progresses

2. Insulin Therapy

• Continuous IV insulin infusion (not subcutaneous initially)
• Goal: Lower glucose gradually (50-75 mg/dL per hour)
• Too-rapid correction can cause brain swelling (cerebral edema), especially in children
• Once glucose reaches ~200-250 mg/dL, glucose is often added to IV fluids to allow continued insulin administration for ketone clearance

3. Electrolyte Replacement

• Potassium: Critical—insulin drives potassium into cells; levels must be carefully monitored and replaced
• Phosphate: May be replaced in severe cases
• Bicarbonate: Rarely needed; body usually self-corrects acidosis once ketone production stops

Monitoring During Treatment

• Blood glucose: Every 1-2 hours
• Electrolytes: Every 2-4 hours
• Ketones: Until cleared
• Vital signs: Continuous or frequent
• Fluid balance: Input/output tracking

Resolution Criteria

DKA is considered resolved when:

• Blood glucose <200 mg/dL
• Blood pH >7.3
• Bicarbonate ≥18 mEq/L
• Ketones clearing (blood ketones <0.6 mmol/L)
• Patient able to eat and drink

💪 Recovery After DKA

In the Hospital

• Transition to subcutaneous insulin: Usually 1-2 hours before stopping IV insulin
• Eating resumes: Start with clear liquids, progress to regular diet
• Identify the trigger: What caused this episode?
• Education review: Sick day rules, ketone testing, when to seek help
• Follow-up arranged: Appointment with diabetes care team

At Home After Discharge

• Follow insulin regimen carefully: May be adjusted from pre-DKA doses
• Monitor more frequently: Check glucose 4-6 times daily for first few days
• Have ketone testing supplies: Blood ketone meter recommended
• Stay hydrated: Continue drinking plenty of fluids
• Rest: DKA is exhausting; recovery takes time
• Attend follow-up: Don't skip your post-discharge appointment

🛡️ Preventing Diabetic Ketoacidosis: Your DKA Defense Plan

Most DKA episodes are preventable. Here's how:

Never Skip Insulin

• Even when sick and not eating: You still need basal insulin
• Set reminders: Use phone alarms for insulin doses
• Have backup supplies: Extra insulin, syringes/pens, pump supplies
• Know your basal rate: If pump fails, know how to give injections

Check Ketones When Appropriate

Test for ketones when:

• Blood glucose >250 mg/dL (especially if persistent)
• You're sick (fever, vomiting, infection)
• You have symptoms like nausea, abdominal pain, or fruity breath
• You're on an SGLT2 inhibitor and feel unwell

Have a Sick Day Plan

Work with your diabetes team to create a written plan that includes:

• When to check glucose and ketones
• How to adjust insulin during illness
• When to contact your healthcare team
• When to go to the emergency room

Wear Medical Identification

Medical ID (bracelet, necklace, or card) ensures emergency responders know you have diabetes if you can't communicate.

🤒 Sick Day Rules for Diabetes

Illness is a major DKA trigger. Follow these rules when you're sick:

The Essential Sick Day Rules

1. Never stop insulin—you may need MORE, not less
2. Check blood glucose every 2-4 hours
3. Test ketones if glucose >250 mg/dL
4. Drink at least 8 oz of fluid per hour (sugar-free if glucose is high)
5. Continue to eat if possible—even small amounts help
6. Take your temperature—fever indicates infection
7. Keep records—glucose, ketones, temperature, food, insulin given

When to Contact Your Healthcare Team

• Blood glucose consistently >300 mg/dL
• Moderate ketones that don't clear with extra insulin
• You're unsure about insulin adjustments
• Illness lasting >24 hours
• Fever >101°F (38.3°C)

When to Go to the Emergency Room

• Large ketones
• Persistent vomiting (can't keep fluids down >4 hours)
• Signs of DKA (fruity breath, rapid breathing, confusion)
• Severe dehydration
• Uncertain about your condition

⚖️ DKA vs. HHS: Understanding the Difference

Both DKA and HHS (Hyperosmolar Hyperglycemic State) are diabetes emergencies, but they differ in important ways.

Why HHS is often more dangerous: Because it develops slowly, people may not seek help until severely dehydrated and mentally altered. Older adults living alone are particularly vulnerable.

Last Reviewed: January 2026