St Emlyn’s Lesson Plans

Recognising and managing diabetic ketoacidosis

Recognise DKA, interpret early treatment trends and escalate electrolyte or neurological deterioration.

Medical Students · 45-minute session

For learners

Before: Allow about 13 minutes in total.

When we meet: We will interpret the initial results and treatment trends, including potassium changes, a near-normal glucose presentation and neurological deterioration.

After: choose a point to follow up in practice

For facilitators

Send: the learner preparation link before teaching.

Bring: Local DKA chart and the serial-results worksheet below, displayed or printed; no infusion setup required.

Run: 45-minute session plan · 30-minute option

Before the session

If you are attending this session, complete the core preparation below before you come. Allow about 13 minutes in total.

Core preparation

JBDS management of DKA in adults, March 2023 · About 10 minutes

Read the diagnostic criteria on printed page 10, the potassium table on page 27, and the monitoring, response and resolution sections on pages 28–30. Focus on what must be measured and when a concerning result needs senior review; you do not need to memorise infusion rates.

https://abcd.care/sites/default/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf

Think about (allow 3 minutes): If glucose falls during DKA treatment but ketones remain high, what still needs to be treated and monitored?

Picture the scene

A young adult with type 1 diabetes has vomiting, diffuse abdominal pain and rapid breathing. They have had difficulty obtaining insulin while away from home.

By the end of the session

Recognise the combination of diabetes or hyperglycaemia, ketosis and acidosis.
Explain why glucose, ketones, potassium and fluid balance need repeated review.
Identify changes that need urgent senior or critical-care review.

After the session

On the next DKA case, review the trend chart with the supervising clinician and identify which findings changed the prescription.

Facilitator guide

Send learners the preparation link several days before teaching. Allow about 13 minutes in total.

Before learners arrive

Obtain the local DKA chart and check that it reflects the current JBDS update.
Confirm glucose/ketone meter availability, insulin safety checks, potassium replacement processes and diabetes escalation contacts.
Review the fictional worksheet against the local chart before teaching. Keep the student discussion on recognising the trends, reporting potassium of 3.4 mmol/L and seeking help; prescribing decisions remain supervised.

Equipment: Local DKA chart and the serial-results worksheet below, displayed or printed; no infusion setup required.

Setup: Reveal the worksheet a row at a time. Small groups follow glucose, ketones, pH or potassium, then combine their findings into one request for supervised reassessment.

If the preparation has not been completed

Replace “Establish the essentials” with five minutes using the JBDS diagnostic criteria, local DKA chart and the worksheet below. Spend two minutes matching the first row to the diagnostic criteria, two identifying the measurements that need repeating, and one agreeing whom a student should call about an unsafe trend. Reveal later rows during case 1.

Suggested session plan

0–5 min — Explore. Ask which single bedside test might be missed in a vomiting patient.
5–10 min — Establish the essentials. Find the diagnostic criteria and potassium section together.
10–32 min — Discuss & Apply. Use 15 minutes on case 1 and 7 on euglycaemic presentation and deterioration.
32–40 min — Consolidate. Use the trend sheet to ask why insulin may still be needed as glucose falls, then identify changes that require urgent review.
40–45 min — Reflect & Transfer. Ask learners to arrange a supervised review of a DKA chart, focusing on which result changed the prescription.

Start the discussion

Read the opening scenario together. Give everyone a moment to think, then ask what concerns them and what they need to know next.

Cases and discussion

Use these cases, or invite an anonymised case from the group that addresses the same questions.

Vomiting with deep, rapid breathing

A 21-year-old has HR 122, BP 110/71, RR 34, glucose 25 mmol/L, blood ketones 5.2 mmol/L, venous pH 7.12, bicarbonate 10 mmol/L and potassium 5.8 mmol/L.

Add this information as the discussion develops:

Reveal missed insulin doses because supplies ran out. Ask how to explore this without blame.
Use the fictional serial results in the worksheet. Glucose falls during treatment, but the other measurements need a separate review.

Ask the group:

Which findings establish DKA?
Does a high initial potassium mean total-body potassium is adequate?
Why may the team need glucose while continuing insulin?
At four hours, what would you report urgently to the supervising clinician?

Discussion notes

Points to draw out:

JBDS adult criteria require ketones above 3 mmol/L or significant ketonuria, glucose above 11 mmol/L or known diabetes, and bicarbonate below 15 mmol/L and/or venous pH below 7.3.
Treatment addresses fluid deficit, insulin deficiency, electrolytes and the precipitant. Students should explain the plan and monitoring alongside the prescribing clinician.
Glucose can improve before ketoacidosis resolves. Follow the current chart for glucose supplementation and insulin-rate adjustment rather than stopping insulin just because glucose falls.
A falling potassium requires prompt chart review; severe abnormality or ECG changes requires urgent senior management.
In the worksheet, ketones remain high and pH remains low at four hours. Potassium has fallen to 3.4 mmol/L, which needs urgent senior review of the local potassium and insulin plan. Students should report the results and concern; they should not independently change an infusion.

Common misconceptions:

Missing the acidosis when interpreting the diagnostic criteria.
Assuming tachypnoea must be a primary respiratory disease.
Calling missed insulin ‘non-compliance’ before understanding access, illness or distress.

For a more experienced group: Ask how the team would adapt treatment for kidney failure or heart failure, and why a standard fluid schedule requires clinical judgement.

The glucose is only 9

An adult taking an SGLT2 inhibitor has vomiting, abdominal pain and tachypnoea during an intercurrent illness. Glucose is 9 mmol/L, ketones 4.5 mmol/L and venous pH 7.20.

Add this information as the discussion develops:

A colleague suggests that the glucose excludes DKA.
During treatment the patient becomes more drowsy and develops a new severe headache.

Ask the group:

What does the medication history add?
What requires reassessment before attributing drowsiness to fatigue?
Which senior teams should be contacted?

Discussion notes

Points to draw out:

Euglycaemic DKA is possible; recognise the combination and seek urgent senior diabetes advice.
Neurological deterioration requires immediate reassessment and escalation, including concern about cerebral oedema and alternative causes.
For 16–18-year-olds, use the adult or paediatric pathway appropriate to the treating service. Paediatric fluids require the paediatric pathway and appropriate supervision.

Common misconceptions:

Using normal-range glucose as a rule-out test.
Explaining all persistent acidosis as continuing ketosis without reviewing chloride, lactate and the trend.

For a more experienced group: Compare ketone clearance with persistent hyperchloraemic acidosis; ask which endpoint the team is following.

DKA: follow the serial results

These fictional results belong to case 1. Reveal one row at a time and describe what has changed before deciding what needs review. They are selected teaching readings, not a complete monitoring schedule.

Time from starting treatment	Glucose (mmol/L)	Blood ketones (mmol/L)	Venous pH	Potassium (mmol/L)
0 hours	25	5.2	7.12	5.8
1 hour	21	4.9	7.15	4.7
2 hours	17	4.8	7.17	4.0
4 hours	12	4.6	7.18	3.4

Which measurements are improving, and which still concern you?
Why does the glucose of 12 mmol/L not show that DKA has resolved?
What would you say when asking the supervising clinician to review the four-hour results?

Worked discussion notes

Use this to practise recognising trends and asking for help. The local DKA chart determines monitoring and treatment.
The ketone fall is slow and acidaemia persists. Falling glucose alone does not show recovery.
The potassium of 3.4 mmol/L needs urgent senior review; do not respond by independently increasing insulin.
Fictional teaching data; human clinical review is required before use.

Fictional teaching exercise. The added values and worked notes await clinical review before use.

Important clinical points

The JBDS bicarbonate threshold for the acidosis criterion is below 15 mmol/L.
Do not dismiss severe hyperkalaemia or ECG changes as automatically self-correcting.
New neurological deterioration during treatment is urgent.

Closing the session

Use these questions to check what the group will take away. Go back over any clinical points that remain unclear.

Why can normal glucose coexist with DKA?
Why is stopping insulin solely because glucose improves unsafe?
Which three changes trigger urgent review during treatment?

Key teaching points:

Assess ketones and acid-base status as well as glucose.
Review biochemical trends alongside the patient’s condition.
Fluid and insulin treatment require repeated electrolyte assessment.
Ask about insulin access, illness and distress when exploring the precipitant.

Before leaving, ask each person to choose one action from After the session and say when they will try it. They complete that follow-up in practice, with supervision where needed.

Adapting the discussion

Uncertainty and local practice

Fluid choice and complex acid-base interpretation need senior judgement, particularly when comorbidity affects the standard pathway.

If the discussion drifts

Which measurement would change what the team does in the next hour?

For a more experienced group

Use the chart to explain the 2023 insulin de-escalation option as glucose falls; do not create a competing local prescription chart.

A 30-minute version

30 minutes: opening 3, chart 5, case 1 14, deterioration 3, consolidation 3, reflection 2.

Evidence and guidance

JBDS 02 DKA in adults 2023 — Diagnostic criteria, monitoring, potassium and updated treatment pathway.https://abcd.care/sites/default/files/site_uploads/JBDS_Guidelines_Current/JBDS_02_DKA_Guideline_with_QR_code_March_2023.pdf
RCEM clinical standards index — Lists 2025 safety flash on euglycaemic DKA with SGLT2 inhibitors.https://rcem.ac.uk/clinical-standards-and-guidance/