Review Question - QID 104339

This patient is presenting in diabetic ketoacidosis (DKA) given her history of type I diabetes, anion gap acidosis, and hyperglycemia. Given her dehydration and very low potassium, the best initial step in management is IV fluids (normal saline) and potassium.

DKA presents in type I diabetics with nausea, vomiting, abdominal pain, and lethargy. The diagnosis can be confirmed by demonstrating an anion gap acidosis and hyperglycemia. The most important initial step in management is to administer IV fluids and correct any electrolyte abnormalities. Patients presenting with hypokalemia should first only be treated with IV fluids and potassium repletion. Once the potassium has normalized, then the patient can be started on insulin while continuously being given IV fluids and potassium. Insulin treatment should occur until the anion gap normalizes. If the patient's blood glucose begins to drop, they can be started on IV dextrose.

Incorrect Answers:
Answer 1: Insulin and potassium are inappropriate as this patient first needs to have their potassium corrected before starting insulin. The patient also needs fluids as DKA patients are typically profoundly dehydrated.

Answer 2: Normal saline and insulin could cause life-threatening dysrhythmias as insulin could cause this patient's potassium to further decline.

Answer 4: Normal saline, insulin, and potassium are incorrect as this patient's potassium is too low to begin insulin. First, the patient's potassium must be within the range of normal. At this point, insulin can be started.

Answer 5: Normal saline, insulin, potassium, and sodium bicarbonate is incorrect as insulin should be held until potassium normalizes. Bicarbonate does not have a clear indication in the management of an acidosis; however, administration of bicarbonate could actually further worsen this patient's hypokalemia.

Bullet Summary:
Patients in DKA with a very low potassium should first be started on IV fluids and potassium before starting insulin therapy.