🧠 CASE MODE

Interactive DKA Management

Work through the emergency department case. Teaching points appear only after you commit to an answer.

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The Case Begins

Arrival

A 24-year-old woman with type 1 diabetes presents with 24 hours of vomiting, diffuse abdominal pain, polyuria and progressive lethargy. She ran out of insulin two days ago.

Vitals: BP 96/58, HR 124, RR 30 and deep, T 37.7Β°C, SpOβ‚‚ 99% RA. She is dry, tachypneic and arousable to voice.

Initial data

  • POC glucose: 468 mg/dL
  • Na 130, K 5.6, Cl 96, HCO₃ 9 mEq/L
  • BUN 32, creatinine 1.4 mg/dL
  • VBG pH 7.14
  • Ξ²-hydroxybutyrate 6.8 mmol/L

ABEM-style decision 1

Which intervention is the most appropriate immediate next step?

Best answer: B. Restore circulating volume first while confirming potassium and beginning cause-directed evaluation. Bicarbonate is not routinely recommended at this pH, and dialysis is not indicated by these data.
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Confirm the Diagnosis

2024 adult consensus: all three components are required

D β€” Diabetes / glucoseGlucose β‰₯200 mg/dL OR prior diabetes
K β€” KetosisΞ²-hydroxybutyrate β‰₯3.0 mmol/L
A β€” AcidosispH <7.3 OR HCO₃ <18 mEq/L

Euglycemic DKA can occur, particularly with SGLT2 inhibitors, pregnancy, reduced intake or partially treated disease.

Bedside calculator

Anion gap = 25 mEq/L. Elevated; interpret with albumin and the full clinical picture.

ABEM-style decision 2

Which finding best establishes the ketone component of DKA?

Best answer: C. Direct blood Ξ²-hydroxybutyrate is preferred. Urine nitroprusside testing does not measure Ξ²-hydroxybutyrate and can underestimate early DKA or appear worse during recovery.
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Fluid Strategy

Assess perfusionShock requires rapid isotonic crystalloid and frequent reassessment. Consider cardiac and renal comorbidity.
Initial replacementIn adults without cardiac or renal compromise, isotonic saline or a balanced crystalloid at approximately 500–1,000 mL/h for the first 2–4 hours is recommended.
Individualize ongoing fluidChoose rate and composition using hemodynamics, intake/output and sodium/osmolality trajectory. Balanced crystalloids may shorten DKA resolution and reduce hyperchloremic acidosis.
Add dextroseWhen glucose falls below 250 mg/dL, add 5–10% dextrose so insulin can continue until ketonemia resolves.

Common mistake

Using a rigid β€œliters for everyone” protocol without reassessment.

Mitigation: smaller boluses and frequent lung, perfusion, urine-output and electrolyte reassessment in older adults, pregnancy, heart failure or kidney disease.

ABEM-style decision 3

After initial resuscitation, glucose is 228 mg/dL but Ξ²-hydroxybutyrate remains 4.2 mmol/L. What is the best next step?

Best answer: D. Glucose often corrects before ketoacidosis. Dextrose prevents hypoglycemia while insulin suppresses ketogenesis and clears Ξ²-hydroxybutyrate.
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Insulin: Stop Ketogenesis

Standard approach

After fluids are underway and K is safe, start short-acting insulin at 0.1 units/kg/h IV for moderate/severe DKA. A bolus is unnecessary when infusion begins promptly.

Mild uncomplicated DKA may be managed with protocolized subcutaneous rapid-acting insulin in an appropriate monitored setting.

Transition

Continue IV insulin until DKA resolves. Start the subcutaneous basal-bolus regimen with 1–2 hours of overlap before stopping IV insulin; account for intake, kidney function and hypoglycemia risk.

Critical action

Do not stop insulin merely because glucose normalizes. Add dextrose and continue insulin until ketonemia and acidosis resolve.

ABEM-style decision 4

The patient weighs 70 kg. K is 4.4 mEq/L after fluids. Which initial IV insulin rate is most appropriate?

Best answer: A. 0.1 units/kg/h Γ— 70 kg = 7 units/h. Potassium is safe to begin insulin, with replacement and close monitoring.
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Electrolytes Drive Safety

FindingActionWhy it matters
K <3.5 mEq/LReplace potassium and delay insulin until K is >3.5.Insulin can precipitate life-threatening hypokalemia.
K 3.5–5.0Usually add 20–30 mmol potassium per liter; target K 4–5.Total-body potassium is depleted despite a normal initial serum value.
K >5.0Do not initially replace; recheck frequently.K generally falls with fluids, insulin and correction of acidosis.
PhosphateNo routine replacement; consider if <1.0 mmol/L with muscle weakness or respiratory/cardiac compromise.Routine therapy has not shown clinical benefit and may cause hypocalcemia.
BicarbonateNot routine; consider only severe acidosis, generally pH <7.0.Potential harms include hypokalemia, paradoxical CNS acidosis and delayed ketone clearance.

ABEM-style decision 5

A patient with DKA has K 3.1 mEq/L. What should occur before insulin?

Best answer: B. Hold insulin and replace potassium until K exceeds 3.5 mEq/L. Continuous cardiac monitoring is prudent in significant hypokalemia.
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Monitoring and Resolution

Track the physiology

  • Capillary glucose every 1–2 hours
  • Electrolytes, creatinine, phosphate, Ξ²-hydroxybutyrate and venous pH about every 4 hours until resolution
  • Vitals, mental status, volume status and urine output
  • Corrected sodium and osmolality when mixed DKA/HHS is possible

Resolution

Ξ²-hydroxybutyrate <0.6 mmol/L plus venous pH β‰₯7.3 or bicarbonate β‰₯18 mEq/L. Glucose should ideally be <200 mg/dL.

The anion gap should not be the sole resolution criterion because saline-associated hyperchloremic acidosis can persist.

Critical actions

  • Identify and treat the precipitant.
  • Watch for hypoglycemia and hypokalemia.
  • Consider cerebral edema if neurologic status worsens.
  • Ensure insulin access, education and follow-up before disposition.

Precipitant checklist

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Case Recap

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Critical actions

  1. Recognize DKA using diabetes/glucose, ketones and acidosis.
  2. Restore perfusion with individualized isotonic crystalloid.
  3. Check and manage potassium before insulin.
  4. Continue insulin with dextrose until ketoacidosis resolves.
  5. Find the precipitant and overlap subcutaneous insulin.

Common mistakes β†’ mitigation

  • Urine ketones alone: use Ξ²-hydroxybutyrate.
  • Insulin with low K: replace K first.
  • Stopping at euglycemia: add dextrose; clear ketones.
  • Routine bicarbonate: reserve for extreme acidosis.
  • Using AG alone: use ketones plus pH/bicarbonate.
Emergency Briefcase Β· Evidence-aligned adult DKA learning experience