Endocrine Emergencies Part 1: DKA

Diabetic ketoacidosis (DKA) represents an acute insulin deficiency triggering a catabolic state characterized by hyperglycemia, ketosis, acidosis, and hyperosmolarity. Effective management requires a prioritized three-pronged approach: assessing fluid status, correcting electrolyte imbalances, and administering insulin. Distinguishing between hypovolemia and dehydration is essential, as the former requires crystalloid resuscitation while the latter necessitates hypotonic fluids. Potassium levels must be stabilized before initiating insulin to prevent life-threatening arrhythmias, particularly in patients with severe whole-body hypokalemia. Clinicians should avoid common pitfalls such as reflexive intubation, bicarbonate administration, and the stigmatization of patients as "non-compliant." Furthermore, providers must maintain a high index of suspicion for euglycemic DKA in patients using SGLT2 inhibitors, as these individuals may present with normal glucose levels despite severe metabolic acidosis. Transitioning off insulin drips requires confirmation that the anion gap has closed and the patient is tolerating oral intake.