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FOCUSED SHIFT VIEW

DKA, HHS & Adrenal Crisis

Sugar, potassium, volume — and never withhold steroids in the crashing steroid-dependent patient.

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Educational first-pass aid. Reassess the patient, confirm doses and use local protocols.

1 · First minutes

  1. Bedside glucose, VBG/ketones, and potassium in every sick diabetic or unexplained shock.
  2. DKA: fluids first, potassium repletion, then insulin. Defer insulin if K⁺ is <3.5 mmol/L.
  3. HHS: slower osmolar correction, hunt the trigger (infection, MI, stroke), watch sodium and neuro status.

2 · Escalate now if

  • Altered mentation with hyperglycemia or ketones
  • K⁺ <3.5 before insulin, or falling K⁺ on treatment
  • Steroid-dependent patient with shock or vomiting
  • SGLT2 inhibitor + acidosis even with a “normal” glucose
  • Headache or falling GCS in a child on a DKA protocol
  • Hypotension that does not respond to fluids (think adrenal, sepsis, ACS)

3 · Immediate workup

  • Glucose, VBG, blood β-hydroxybutyrate (urine if unavailable), ECG
  • Potassium on the blood gas while the lab is pending

4 · Don’t miss

  • Diabetic ketoacidosis
    Diabetes history or glucose ≥200 mg/dL, β-hydroxybutyrate ≥3 mmol/L (or urine ketones ≥2+), and pH <7.3 and/or bicarbonate <18 mmol/L. Euglycemic DKA on SGLT2 inhibitors is easy to miss — check ketones when the story fits even if glucose is modest.
  • Hyperosmolar hyperglycemic state
    Glucose ≥600 mg/dL, effective osmolality >300 or total >320 mOsm/kg, β-hydroxybutyrate <3 mmol/L, pH ≥7.3 and bicarbonate ≥15 mmol/L; altered mentation is not required — huge water deficit; correct slowly to avoid cerebral edema.
  • Adrenal crisis
    Shock, hyponatremia, hyperkalemia, or hypoglycemia in a steroid-dependent, pituitary, or meningococcemia patient — hydrocortisone 100 mg IV now.
  • Precipitant ACS / sepsis / pancreatitis
    The crisis is often triggered — ECG, cultures, lipase as indicated. Treat the trigger with the protocol.
  • Hypokalemia during insulin
    Total-body K⁺ is low even when the first value is normal; insulin drives K⁺ in — replace and monitor.

5 · Disposition lane

Admit (ward / HDU)

Uncomplicated DKA responding on a protocol, new diabetes needing education, HHS with improving osmolality under monitoring.

ICU

Severe acidosis, shock, HHS with coma, pediatric DKA, adrenal crisis, cerebral edema, or a dangerous precipitant (ACS, sepsis).