Alcoholic Ketoacidosis: Etiologies, Evaluation, and Management

J Emerg Med. 2021 Dec;61(6):658-665. doi: 10.1016/j.jemermed.2021.09.007. Epub 2021 Oct 26.


Background: Alcoholic ketoacidosis (AKA) is defined by metabolic acidosis and ketosis in a patient with alcohol use. This is a common presentation in the emergency department (ED) and requires targeted therapies.

Objective: This narrative review evaluates the pathogenesis, diagnosis, and management of AKA for emergency clinicians.

Discussion: AKA is frequently evaluated and managed in the ED. The underlying pathophysiology is related to poor glycogen stores and elevated nicotinamide adenine dinucleotide and hydrogen. This results in metabolic acidosis with elevated beta-hydroxybutyrate levels. Patients with AKA most commonly present with a history of alcohol use (acute or chronic), poor oral intake, gastrointestinal symptoms, and ketoacidosis on laboratory assessment. Patients are generally dehydrated, and serum glucose can be low, normal, or mildly elevated. An anion gap metabolic acidosis with ketosis and electrolyte abnormalities are usually present on laboratory evaluation. Management includes fluid resuscitation, glucose and vitamin supplementation, electrolyte repletion, and evaluation for other conditions.

Conclusions: Emergency clinician knowledge of the evaluation and management of AKA is essential in caring for these patients.

Keywords: acidosis; alcohol; alcoholic ketoacidosis; malnutrition.

Publication types

  • Review

MeSH terms

  • Acidosis* / diagnosis
  • Acidosis* / etiology
  • Acidosis* / therapy
  • Alcoholism* / complications
  • Fluid Therapy
  • Glucose
  • Humans
  • Ketosis* / diagnosis
  • Ketosis* / etiology
  • Ketosis* / therapy


  • Glucose