A 24-year-old woman with type 1 diabetes presents with 2 days of vomiting and abdominal pain. Blood glucose is 480 mg/dL, pH is 7.18, bicarbonate is 9 mEq/L, and urine ketones are strongly positive. After securing the airway, what is the FIRST therapeutic priority?
- A Intravenous isotonic (0.9%) sodium chloride ✓
- B Intravenous regular insulin bolus of 0.1 U/kg
- C Intravenous sodium bicarbonate
- D Potassium replacement at 20 mEq/h
Correct answer: A. Intravenous isotonic (0.9%) sodium chloride
Explanation
Fluid resuscitation with isotonic saline is the initial step in diabetic ketoacidosis because patients typically have a 5 to 8 L deficit, and restoring intravascular volume lowers glucose by dilution and improved renal perfusion even before insulin acts. An insulin bolus is no longer recommended as it risks hypokalaemia and cerebral oedema. Potassium is added only once serum potassium falls below 5.3 mEq/L and urine output is confirmed. Bicarbonate is reserved for pH below 6.9.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.