A 10-year-old boy with a known history of type 1 diabetes mellitus is brought to the emergency department with altered mental status, deep and rapid breathing, and a fruity odor to his breath. Laboratory evaluation confirms the diagnosis of severe diabetic ketoacidosis (DKA). Arrange the following initial management steps in the correct chronological order according to standard pediatric DKA treatment protocols.
- 1Secure the airway and establish peripheral intravenous access.
- 2Administer a 10 to 20 mL/kg bolus of 0.9% normal saline over 1 to 2 hours.
- 3Initiate a continuous intravenous regular insulin infusion at 0.05 to 0.1 units/kg/hr.
- 4Add 5% dextrose to the maintenance intravenous fluids when blood glucose reaches 250 to 300 mg/dL.
Answer
The correct sequence is: Secure airway and establish IV access -> Administer normal saline bolus -> Initiate continuous IV insulin infusion -> Add dextrose to IV fluids when glucose drops to 250-300 mg/dL.
The management of pediatric diabetic ketoacidosis strictly follows a stepwise approach to safely correct dehydration and metabolic derangements while minimizing the risk of cerebral edema. The correct chronological sequence is securing the airway and IV access (basic ABCs), followed by volume expansion with isotonic fluids. Only after initial fluid resuscitation (usually after the first hour) is a continuous insulin infusion started. Finally, as blood glucose falls below 300 mg/dL, dextrose is added to the IV fluids to prevent hypoglycemia, allowing the insulin to continue clearing the ketoacidosis.
Step-by-Step Solution
Key Concept
The standard sequence of pediatric DKA resuscitation prioritizes volume expansion before insulin administration to mitigate the risk of cerebral edema.