Acetone Breath, Dry Mouth, and Thirst: Recognizing Diabetic Ketoacidosis (DKA)

Diabetic ketoacidosis (DKA) is a life-threatening complication of absolute insulin deficiency (primarily Type 1 DM). Recognize the triad: hyperglycemia (>250 mg/dL), ketonemia, metabolic acidosis (pH <7.3, bicarbonate <15 mEq/L).

Classic Symptoms

• Fruity/acetone breath (exhaled acetone from ketolysis)
• Polyuria & polydipsia (osmotic diuresis from hyperglycemia → dehydration)
• Dry mouth, poor skin turgor (dehydration)
• Kussmaul respirations (deep, rapid, labored — compensatory respiratory alkalosis)
• Nausea, vomiting, abdominal pain (ketones irritate GI; ↑ intracranial pressure)
• Confusion, lethargy, coma (cerebral edema, acidosis, hyperosmolality)
• Tachycardia, hypotension (volume depletion)

Precipitating Factors

• Infection (pneumonia, UTI)
• Insulin omission/non-adherence
• New-onset T1DM
• MI, stroke, trauma, surgery
• Drugs: SGLT2 inhibitors (euglycemic DKA), corticosteroids

Emergency Management

1. IV fluids (0.9% NaCl → 0.45% NaCl) — restore perfusion, correct dehydration
2. IV insulin infusion (0.1 U/kg/h) — suppress ketogenesis, lower glucose
3. Electrolyte replacement (K⁺ critical — monitor q1–2h)
4. Bicarbonate only if pH <6.9 (controversial)
5. Treat underlying trigger

DKA is a medical emergency. Mortality <1% with protocolized care; ↑ with cerebral edema (pediatric), comorbidity, delay. Educate patients on sick-day rules and ketone testing.