A 32-year-old male with type 1 diabetes presents to the emergency department with vomiting, abdominal pain, and Kussmaul respirations. Blood glucose is 480 mg/dL, arterial pH is 7.18, and serum bicarbonate is 11 mEq/L with positive serum ketones. What is the most critical initial therapeutic step?

Answer and explanation

Correct answer: D. Intravenous 0.9% normal saline fluid resuscitation

  1. Step 1: In diabetic ketoacidosis (DKA), patients suffer from severe intravascular volume depletion (typically 5 to 8 liters fluid deficit).
  2. Step 2: The immediate primary priority before insulin administration is aggressive intravenous hydration with 0.9% isotonic saline (1000-1500 mL in the first hour) to restore tissue perfusion and hemodynamics.
  3. Step 3: Premature insulin administration before fluid resuscitation can cause cardiovascular collapse.
Answer
Intravenous 0.9% normal saline fluid resuscitation.
Why not the others: 'Subcutaneous rapid-acting insulin bolus' is inappropriate for severe DKA requiring continuous IV insulin after fluids; 'Intravenous sodium bicarbonate infusion' is not indicated unless pH falls below 6.9; 'Intravenous potassium chloride push' is lethal and must only be given as slow infusion in IV bags.

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