A male college student, aged , is brought to the emergency department after his roommate found him confused and vomiting. He has been complaining of abdominal pain for the past day. On physical examination, he appears lethargic and has dry mucous membranes. Vital signs demonstrate a heart rate of beats per minute and a blood pressure of mmHg. Point-of-care capillary glucose testing shows a level of mg/dL. An arterial blood gas analysis reveals a pH of . A dipstick urinalysis is strongly positive for ketones. The patient is diagnosed with diabetic ketoacidosis. Arrange the following interventions in the most appropriate chronological order for his initial management.
- 1Administer an intravenous bolus of normal saline
- 2Assess the serum potassium level
- 3Initiate a continuous intravenous regular insulin infusion
- 4Transition to a basal-bolus subcutaneous insulin regimen
Answer
The correct sequence is: Administer normal saline, assess potassium level, initiate intravenous insulin, and finally transition to subcutaneous insulin.
In the management of diabetic ketoacidosis, the first and most critical step is volume expansion with isotonic saline to restore perfusion. Once fluids are running, the serum potassium must be checked. If potassium is severely low ( mEq/L), insulin must be delayed until potassium is repleted, because insulin shifts potassium intracellularly and can cause fatal arrhythmias. If potassium is safe, an intravenous regular insulin infusion is started to stop ketogenesis and close the anion gap. Once the ketoacidosis has resolved (closed anion gap) and the patient can eat, they are transitioned to subcutaneous maintenance insulin.
Step-by-Step Solution
Key Concept
The initial management of diabetic ketoacidosis (DKA) prioritizes aggressive fluid resuscitation and potassium assessment before insulin administration.