Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) are two conditions that can present similarly. Differentiating them can be a challenge. A thorough review of the literature on treatment of these two conditions was published in Emergency Medicine Practice, including topics like arterial blood gas, insulin bolus, and IV fluid replacement. The following is a summary of the treatment guidelines.

DKA vs HHS 1,2


DKA, mild

DKA, moderate

DKA, severe



7.25 - 7.30

7.00 - 7.24


Normal (or mild decrease)

Serum Glucose

Typically >250*

Typically >250*

Typically >250*


Serum Bicarb (mEq/L)


10 to <15



Urine Ketones




Trace or none

Serum Ketones (Beta-hydroxybutyrate)





Serum Osm.





Anion Gap




Usually normal

Mental Status


Alert, Drowsy

Stupor, Coma

Stupor, Coma


  • Diabetic Ketoacidosis (DKA) – uncontrolled hyperglycemia, metabolic acidosis, and increased total body ketones. 1,2,3
  • Hyperosmolar hyperglycemic state (HHS) – severe hyperglycemia, hyperosmolality, and dehydration in the absence of significant ketoacidosis. 1,2,3


  1. Fluid resuscitation: 2,3
    • NS (0.9%NaCl) 15-20 ml/kg or 1-1.5 liters in first hour … THEN
    • If corrected serum Na is low, cont. NS @ 250-500 ml/hr
    • If corrected serum Na is high or normal, change to 0.45% NaCl @ 250-500 ml/hr
    • Once plasma glucose reaches 200 mg/dl (DKA) or 300 mg/dl (HHS) change to 5%dextrose/0.45%NaCl @150-200 ml/hr
  2. Potassium: 1,2,3,4 (Hold insulin until K+ level is known)
    • Establish urine output 50 ml/hr
    • K+ > 5.2 mEq/L – no replacement, recheck q2 hours
    • K+ 3.3-5.2 mEq/L – give 20-30 mEq K+ in each liter of IVF to maintain serum K+ between 4-5 mEq/L. Consider oral replacement.
    • K+ < 3.3 mEq/L – HOLD INSULIN and give 20-30 mEq K+ per hour until serum level > 3.3 mEq/L. Consider oral replacement.
  3. Insulin:
    • Start Infusion (no bolus3,4) 0.1-0.14 units/Kg/hr1-5
    • DKA1,2,3– when serum glucose is 200, maintain plasma glucose 150-200 until resolution of ketoacidosis
      • Reduce insulin to 0.02-0.05 units/Kg/hr OR
      • Change to rapid acting subcutaneous insulin 0.1U/Kg every 2 hours
    • HHS1,2,3– when serum glucose is 300, maintain plasma glucose 200-300 until patient alert.
      • Reduce insulin to 0.02-0.05 units/Kg/hr OR
      • Change to rapid acting subcutaneous insulin 0.1U/Kg every 2 hours
  4. Replete electrolytes:
    • Magnesium level should be corrected in hypokalemic patients.
    • Serum phosphate concentration <1.0 mg/dl may be repleated with 20–30 mEq/l potassium phosphate mixed with IVF. 1,2,3

Precipitating Factors

  • Most commonly infection 1,2,3
  • Inadequate insulin or discontinuation 1,2,3
  • Pancreatitis 2,3
  • MI 1,2,3
  • CVA 1,2,3
  • Drugs 2,3
    • corticosteroids
    • thiazides
    • sympathomimetic agents
    • antipsychotics
    • pentamidine


  • DKA: 2,3
    • <1% Adults
    • >5% has been reported in the elderly and in patients with concomitant life-threatening illnesses
    • DKA is the most common cause of death in children and adolescents with type 1 diabetes and accounts for half of all deaths in diabetic patients younger than 24 years of age
  • HHS: 5-20% 2,3

Other Considerations

  • VBG is equivalent to ABG and adequate for use in DKA and HHS.8-11 However, ABG analysis rarely changes management in the ED. 9
  • IV bicarbonate therapy does not show an improvement in patient oriented outcomes.6,7
  • Insulin bolus increases risk of hypoglycemic event without improving patient oriented outcomes.4,5
  • Measurement of Beta-hydroxybutyrate has been shown to be accurate for the diagnosis of DKA in adults and children. A level >3.8 mmol/L in adults or >3.0 mmol/L in children is diagnostic.12

Further Reading

Diabetic Hyperglycemic Emergencies: A Systematic Approach

Date Release: Feb 2020

Follow a systematic approach for managing patients with DKA and HHS in the ED: volume repletion, correction of hyperglycemia, and electrolyte replacement.


  1. Dingle HE, Slovis C. Diabetic hyperglycemic emergencies: a systematic approach. Emerg Med Pract. 2020 Feb;22(2):1-20. Epub 2020 Feb 1. PMID: 31978294.
  2. Kitabchi AE, Umpierrez GE, Miles JM, et al. Hyperglycemic crises in adult patients with diabetes. Diabetes Care. 2009;32(7):1335-1343.
  3. Westerberg DP. Diabetic ketoacidosis: evaluation and treatment. Am Fam Physician. 2013;87(5):337-46.
  4. Arora S, Cheng D, Wyler B, Menchine M. Prevalence of hypokalemia in ED patients with diabetic ketoacidosis. Am J Emerg Med. 2012;30(3):481-4.
  5. Goyal N, Miller JB, Sankey SS, Mossallam U. Utility of initial bolus insulin in the treatment of diabetic ketoacidosis. J Emerg Med. 2010;38(4):422-7.
  6. Chua HR, Schneider A, Bellomo R. Bicarbonate in diabetic ketoacidosis – a systematic review. Ann Intensive Care. 2011;1(1):23.
  7. Duhon B, Attridge RL, Franco-martinez AC, Maxwell PR, Hughes DW. Intravenous sodium bicarbonate therapy in severely acidotic diabetic ketoacidosis. Ann Pharmacother. 2013;47(7-8):970-5.
  8. Kelly AM. Review article: Can venous blood gas analysis replace arterial in emergency medical care. Emerg Med Australas. 2010;22(6):493-8.
  9. Ma OJ, Rush MD, Godfrey MM, Gaddis G. Arterial blood gas results rarely influence emergency physician management of patients with suspected diabetic ketoacidosis. Acad Emerg Med. 2003;10(8):836-41.
  10. Bloom BM, Grundlingh J, Bestwick JP, Harris T. The role of venous blood gas in the emergency department: a systematic review and meta-analysis. Eur J Emerg Med. 2014;21(2):81-8.
  11. Menchine M, Probst MA, Agy C, Bach D, Arora S. Diagnostic accuracy of venous blood gas electrolytes for identifying diabetic ketoacidosis in the emergency department. Acad Emerg Med. 2011;18(10):1105-8.
  12. Sheikh-Ali M, Karon BS, Basu A, Kudva YC, Muller LA, Xu J, Schwenk WF, Miles JM. Can serum beta-hydroxybutyrate be used to diagnose diabetic ketoacidosis? Diabetes Care. 2008 Apr;31(4):643-7.

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Last Updated on January 25, 2023

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