A 22-year-old male with type 1 diabetes presents with nausea, vomiting, abdominal pain, and rapid deep breathing (Kussmaul respiration). Fingerstick glucose is 420 mg/dL. Arterial blood gas shows pH 7.18, bicarbonate 10 mEq/L, and urine dipstick reveals 3+ ketones. What is the initial cornerstone of emergency management?

Answer and explanation

Correct answer: C. Aggressive intravenous fluid resuscitation with isotonic 0.9% normal saline

  1. Step 1: Identify metabolic emergency: Diabetic ketoacidosis (DKA) characterized by hyperglycemia, metabolic acidosis, and ketonemia.
  2. Step 2: Recognize immediate pathophysiological deficit: Patients with DKA suffer from profound volume contraction (often 5 to 8 liters deficit).
  3. Step 3: Prioritize initial resuscitation step: Restoration of circulating intravascular volume with isotonic saline (0.9% NaCl) is the essential initial priority before or alongside starting continuous IV insulin.
Answer
Aggressive intravenous fluid resuscitation with isotonic 0.9% normal saline.
Why not the others: 'Insulin before fluids' risks worsening hypovolemia and hypokalemia; 'bicarbonate push' is not indicated at this pH; 'oral cephalosporins' do not treat diabetic ketoacidosis.

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