A 28-year-old man with type 1 diabetes presents with nausea, vomiting, and abdominal pain for 2 days. He stopped insulin a week ago. On examination, he is dehydrated with Kussmaul breathing. Blood glucose is 480 mg/dL, arterial pH is 7.18, serum bicarbonate is 8 mEq/L, and urine ketones are strongly positive. Serum potassium is 5.8 mEq/L. Which is the most appropriate initial step in management?
- A Intravenous 0.9% normal saline bolus ✓
- B Intravenous insulin bolus followed by continuous infusion
- C Immediate intravenous potassium replacement
- D Intravenous sodium bicarbonate
Correct answer: A. Intravenous 0.9% normal saline bolus
Explanation
The immediate priority in diabetic ketoacidosis is aggressive fluid resuscitation with isotonic saline to restore intravascular volume and improve tissue perfusion. Insulin therapy should begin only after initial fluid resuscitation and once potassium is confirmed to be at least 3.3 mEq/L. Although serum potassium reads 5.8 mEq/L, total body potassium is depleted, and levels will fall rapidly with insulin. 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.