Question 1 of 4

A 37-year-old male presents to the ED with altered mental status. He was found unconscious in the bathroom at work. On exam, he is arousable to painful stimulus, muttering incoherently. His airway is intact and he has bilateral breath sounds. His initial vital signs are blood pressure (BP) 95/47, P 110, respiratory rate (RR) 14, O2% 97% on room air, T 99.4. He has dry mucus membranes. Fingerstick glucose is 396. Lab work reveals a normal CBC, 3+ acetone, Na 121, Cl- 97, HCO3 9, K 3.0, Mg 2.9, Phos 1.5, AG 29. Which of the following is the first priority in caring for this patient?

IV bicarbonate

IV lactated ringers

IV phosphate

IV potassium

IV saline

In patients with diabetes mellitus, it is very important to prioritize therapeutic interventions. The order of therapeutic priorities is volume resuscitation first and foremost. Patients often have a fluid deficit of 5–10 L. Potassium deficits should be addressed next. Diabetic ketoacidosis (DKA) patients often have profound total-body potassium deficits. For an initial potassium level between 3.3 and 5.3 mEq/L, with established urine output, potassium should be replaced at a rate of 10 mEq KCL per hour for 4 hours. Insulin may be given, but only after volume resuscitation and potassium deficits have been addressed. It may be administered at a bolus of 0.1 units/kg and followed by a drip of 0.1 units/kg per hour. In general, IV phosphate therapy should only be initiated if the serum level is <1.0 mg/dL. Routine use of IV bicarbonate is not recommended in the treatment of DKA.

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