Two adults arrive simultaneously. Client A has type 1 diabetes, glucose 580 mg/dL, pH 7.18, anion gap 24, marked ketones, and Kussmaul respirations. Client B has type 2 diabetes, glucose 920 mg/dL, pH 7.34, trace ketones, profound dehydration, hypernatremia, and obtundation. Which initial actions are correct? Select all that apply.
Select All That Apply
Choose your responses, then check the answer.
Explanation
Client A has DKA with ketosis and metabolic acidosis; Client B has HHS with extreme hyperglycemia, profound dehydration, hyperosmolality, and altered mental status (Choice 3). Begin isotonic saline or balanced crystalloid resuscitation while individualizing for cardiac and renal risk (Choice 4). In DKA, if potassium is below 3.5 mEq/L, replace potassium and delay insulin until it rises above 3.5; otherwise start IV insulin as prescribed (Choice 1). When glucose falls below 250 mg/dL, add 5% to 10% dextrose and continue insulin until ketonemia and acidosis resolve (Choice 2). In HHS, avoid rapid falls in glucose, sodium, and osmolality and follow the protocol for fluids and insulin (Choice 5). Routine bicarbonate is not indicated; current consensus considers it only for severe acidosis around pH below 7.0 (Choice 6).
DKA vs HHS DKA (Type 1 typical): BG 250-600, pH <7.30, anion gap large, ketones positive, Kussmaul, fruity breath, abdominal pain HHS (Type 2 typical): BG >600 (often >1000), pH >7.30, anion gap normal, ketones trace, profound dehydration, severe hyperosmolality, obtunded, NO Kussmaul
Both: Initial Priorities 1. IV access × 2, ABCs, monitor 2. Aggressive isotonic fluid (0.9% NaCl 1 L bolus, then 250-500 mL/hr) 3. Labs: BG, BMP, anion gap, ABG, ketones, osmolality, lactate 4. Cardiac monitor for K+ shifts
DKA Insulin Protocol 1. Verify K+ at least 3.3 mEq/L BEFORE insulin (insulin drives K+ into cells → fatal hypokalemia) 2. Regular insulin IV infusion 0.1 unit/kg/hr 3. Add D5 0.45% NaCl when BG ~200 4. Continue insulin until anion gap closes 5. Bicarbonate ONLY if pH <6.9
HHS Specifics - SLOW correction: avoid cerebral edema - Larger fluid deficit (8-12 L) - Lower-dose insulin once volume restored - Often precipitated by infection, MI, stroke, dehydration
Memory Tip "DKA = Acid + Ketones + Kussmaul; HHS = Higher BG, No ketones, Slower correction"
ScenarioTwo ED clients simultaneously: Client A T1DM DKA (BG 580, pH 7.18, ketones 4+, Kussmaul, fruity breath, lethargic) and Client B T2DM HHS (BG 920, pH 7.34, ketones trace, severe dehydration, obtunded, hypernatremic).
Priority Map1. Differentiation: DKA vs HHS by ketones + pH/anion gap + BG level2. Both: aggressive IV NS resuscitation3. DKA insulin: K+ ≥3.3 first, then 0.1 unit/kg/hr4. DKA glucose ~200: add D5 0.45% NS, continue insulin until anion gap closes5. HHS: slow osmolality correction, lower-dose insulin
Diabetic Ketoacidosis (DKA) — Acute decompensation of diabetes characterized by hyperglycemia (typically 250-600 mg/dL), metabolic acidosis (pH <7.30, HCO3 <18), elevated anion gap, ketonemia/ketonuria, and dehydration. Common precipitants: infection, missed insulin, new-onset T1DM, MI. Classic features: Kussmaul respirations, fruity (acetone) breath, abdominal pain, polyuria/polydipsia. Treatment: aggressive isotonic IV fluid, insulin infusion AFTER K+ check (≥3.3), electrolyte replacement, dextrose addition when BG ~200, continued insulin until anion gap closes.
Hyperosmolar Hyperglycemic State (HHS) — Acute decompensation of T2DM with extreme hyperglycemia (often >600 to >1000 mg/dL), severe dehydration, profound hyperosmolality, minimal or absent ketosis, pH typically >7.30, and altered mental status often progressing to coma. Larger fluid deficit (8-12 L) than DKA. Higher mortality (10-20%). Treatment: aggressive but careful isotonic fluid replacement, slow correction of osmolality and hypernatremia to avoid cerebral edema, lower-dose insulin once volume is restored, identify and treat precipitant (often infection, MI, stroke).
DKA Insulin and Potassium Protocol — Insulin drives K+ intracellularly and can precipitate fatal hypokalemia. Protocol: verify serum K+ ≥3.3 mEq/L BEFORE starting insulin; if K+ <3.3, replace potassium first and hold insulin. Regular insulin IV infusion 0.1 unit/kg/hr (some protocols start with 0.1 unit/kg bolus). When BG falls to ~200 mg/dL, add D5 0.45% NaCl while continuing the insulin drip. Continue insulin until the anion gap closes (not until BG normalizes), then transition to subcutaneous insulin with overlap. Bicarbonate is NOT routine — consider only if pH <6.9.