Examkin

Question

Difficulty: MediumEndocrinology and Metabolism

An unresponsive 22-year-old male is brought to the emergency department by his parents. He has a history of type 1 diabetes mellitus but lost his insurance and ran out of his medication a week ago. Capillary blood glucose is 540 mg/dL540\text{ mg/dL}. Vital signs show a blood pressure of 85/50 mm Hg85/50\text{ mm Hg}, pulse of 128/min128\text{/min}, and respirations of 28/min28\text{/min} with deep, sighing breaths. Laboratory results reveal an arterial pH of 7.157.15, serum bicarbonate of 10 mEq/L10\text{ mEq/L}, and serum potassium of 4.8 mEq/L4.8\text{ mEq/L}. Urinalysis is strongly positive for ketones. Arrange the following management steps in the correct chronological sequence for the optimal treatment of this patient's acute condition.

  1. 1Infuse isotonic (0.9%) saline intravenously
  2. 2Initiate a continuous intravenous regular insulin infusion
  3. 3Add 5% dextrose to the intravenous fluid regimen
  4. 4Administer subcutaneous long-acting insulin

Answer

The correct chronological sequence for managing this patient is: 1) Infuse isotonic (0.9%) saline intravenously, 2) Initiate a continuous intravenous regular insulin infusion, 3) Add 5% dextrose to the intravenous fluid regimen, and 4) Administer subcutaneous long-acting insulin.
The management of diabetic ketoacidosis follows a strict protocol to prevent severe complications. First, isotonic saline is given to restore volume in this hypotensive patient. Second, IV insulin is started (since potassium is safe at 4.8 mEq/L) to shut off lipolysis and resolve acidosis. Third, as glucose drops faster than ketones clear, dextrose must be added to IV fluids when glucose hits 200-250 mg/dL to prevent hypoglycemia while insulin continues. Finally, once the anion gap closes, subcutaneous insulin is given to provide overlap before the IV drip is stopped.

Step-by-Step Solution

1
Administer aggressive intravenous fluid resuscitation with 0.9% saline.
Expands intravascular volume, stabilizes blood pressure, and improves renal perfusion.
The patient is hypotensive and profoundly dehydrated due to osmotic diuresis. Fluids must be given first to prevent cardiovascular collapse.
2
Start a continuous intravenous regular insulin infusion.
Suppresses ketone production and lowers blood glucose.
Insulin is required to correct the underlying metabolic acidosis, but it must be started after fluids and only when potassium is >3.3 mEq/L (his is 4.8 mEq/L).
3
Incorporate 5% dextrose into the IV fluids once glucose reaches 200-250 mg/dL.
Maintains blood glucose in a safe range while continuous insulin is administered.
The ketoacidosis takes longer to resolve than the hyperglycemia. Adding dextrose prevents iatrogenic hypoglycemia while the insulin drip continues to close the anion gap.
4
Transition to subcutaneous long-acting insulin.
Provides basal insulin coverage for maintenance.
Once the anion gap is closed and the patient can eat, subcutaneous insulin must be given 1-2 hours prior to stopping the IV drip to prevent rebound ketoacidosis.

Key Concept

The stepwise management of diabetic ketoacidosis (DKA) prioritizes volume resuscitation, followed by correction of acidosis with continuous insulin, prevention of hypoglycemia with dextrose, and finally transition to subcutaneous insulin.
Estimated Time:1m 30s
Rate this question

Topics

Endocrinology and Metabolism

More questions from this topic