A 16-year-old woman presents to the emergency department for evaluation of acute vomiting and abdominal pain. Onset was roughly 3 hours ago while she was sleeping. She has no known past medical history. Her family history is positive for hypothyroidism and diabetes mellitus in her maternal grandmother. On examination, she is found to have fruity breath and poor skin turgor. She appears fatigued and her consciousness is slightly altered. Laboratory results show a blood glucose level of 691 mg/dL, sodium of 125 mg/dL, and elevated serum ketones. Of the following, which is the next best step in patient management?

Administer IV fluids and insulin

Initiate basal-bolus insulin regimen

Initiate insulin glargine 10 units at bedtime only

Initiate oral antidiabetic medications

Initiate insulin aspart at mealtimes only

A previously healthy 14-year-old girl is brought to the emergency department by her mother because of abdominal pain, nausea, and vomiting for 6 hours. Over the past 6 weeks, she has also had increased frequency of urination, and she has been drinking more water than usual. She has lost 6 kg (13 lb) over the same time period despite having a good appetite. Her temperature is 37.1°C (98.8°F), pulse is 125/min, respirations are 32/min, and blood pressure is 94/58 mm Hg. She appears lethargic. Physical examination shows deep and labored breathing and dry mucous membranes. The abdomen is soft, and there is diffuse tenderness to palpation with no guarding or rebound. Urine dipstick is positive for ketones and glucose. Further evaluation is most likely to show which of the following findings?

Serum glucose concentration > 800 mg/dL

An 8-year old boy is brought to the emergency department because he has been lethargic and has had several episodes of nausea and vomiting for the past day. He has also had increased thirst over the past two months. He has lost 5.4 kg (11.9 lbs) during this time. He is otherwise healthy and has no history of serious illness. His temperature is 37.5 °C (99.5 °F), blood pressure is 95/68 mm Hg, pulse is 110/min, and respirations are 30/min. He is somnolent and slightly confused. His mucous membranes are dry. Laboratory studies show: Hemoglobin 16.2 g/dL Leukocyte count 9,500/mm3 Platelet count 380,000/mm3 Serum Na+ 130 mEq/L K+ 5.5 mEq/L Cl- 99 mEq/L HCO3- 16 mEq/L Creatinine 1.2 mg/dL Glucose 570 mg/dL Ketones positive Blood gases, arterial pH 7.25 pCO2 21 mm Hg Which of the following is the most appropriate next step in management?

Intravenous hydration with 0.9% normal saline and insulin

Intravenous hydration with 0.45% normal saline and insulin

Intravenous hydration with 5% dextrose solution and 0.45% normal saline

Intravenous hydration with 0.9% normal saline and potassium chloride

A previously healthy 10-year-old boy is brought to the emergency room by his mother 5 hours after the onset of abdominal pain and nausea. Over the past 2 weeks, he has also had progressive abdominal pain and a 4-kg (8.8-lb) weight loss. The mother reports that her son has been drinking more water than usual during this period. Last week he wet his bed three times despite being completely toilet-trained since 3 years of age. His temperature is 37.8°C (100°F), pulse is 128/min, respirations are 35/min, and blood pressure is 95/55 mm Hg. He appears lethargic. Physical examination shows deep and labored breathing and dry mucous membranes. The abdomen is soft, and there is diffuse tenderness to palpation with no guarding or rebound. Serum laboratory studies show: Na+ 133 mEq/L K+ 5.9 mEq/L Cl- 95 mEq/L HCO3- 13 mEq/L Urea nitrogen 25 mg/dL Creatinine 1.0 mg/dL Urine dipstick is positive for ketones and glucose. Further evaluation is most likely to reveal which of the following?

Serum glucose concentration > 600 mg/dL

A 27-year-old man presents to the emergency department with his family because of abdominal pain, excessive urination, and drowsiness since the day before. He has had type 1 diabetes mellitus for 2 years. He ran out of insulin 2 days ago. The vital signs at admission include: temperature 36.8°C (98.2°F), blood pressure 102/69 mm Hg, and pulse 121/min. On physical examination, he is lethargic and his breathing is rapid and deep. There is a mild generalized abdominal tenderness without rebound tenderness or guarding. His serum glucose is 480 mg/dL. Arterial blood gas of this patient will most likely show which of the following?

↓ pH, ↓ bicarbonate and ↑ anion gap

↑ pH, ↑ bicarbonate, and normal pCO2

↑ pH, normal bicarbonate and ↓ pCO2

↓ pH, ↓ bicarbonate and normal anion gap

↓ pH, normal bicarbonate and ↑ pCO2

Diabetic ketoacidosis in children

Diagnosis & Severity - The Sweet & Sour Test

Triad: Hyperglycemia + Ketosis + Acidosis
- Blood Glucose: > 200 mg/dL
- Venous pH: < 7.3 or HCO₃⁻ < 15 mmol/L
- Ketones: Present in urine or blood

⭐ In hyperglycemia, measured sodium is falsely low (pseudohyponatremia). Always calculate corrected sodium, a frequent exam topic.

Corrected Sodium: $Na_{corrected} = Na_{measured} + 1.6 \times \frac{(Glucose_{mg/dL} - 100)}{100}$

Pathophysiology - The Chaos Cascade

Absolute or relative insulin deficiency, coupled with excess counter-regulatory hormones (glucagon, cortisol), initiates the crisis.
This dual hormonal imbalance drives two main pathological processes:
- Hyperglycemia: Leads to glycosuria, osmotic diuresis, profound dehydration, and electrolyte loss.
- Ketosis: Unrestrained lipolysis releases free fatty acids, which are converted in the liver to ketone bodies (β-hydroxybutyrate & acetoacetate), causing a high anion-gap metabolic acidosis.

⭐ The predominant ketone is β-hydroxybutyrate, but standard urine nitroprusside tests only detect acetoacetate, potentially underestimating the degree of ketosis.

Management: Fluids & Insulin - The Balancing Act

Initial Resuscitation: Start with 10-20 ml/kg 0.9% Saline bolus over 1-2 hrs. AVOID over-aggressive rehydration.
Deficit Correction: Replace remaining fluid deficit slowly and evenly over 48 hours using 0.45-0.9% NS.
Insulin Infusion: Begin 1-2 hours AFTER starting fluids.
- Dose: 0.05-0.1 units/kg/hr. NO IV insulin bolus.
Glucose Titration: Add 5% Dextrose to IV fluids when blood glucose falls to ~250-300 mg/dL to prevent hypoglycemia, allowing insulin to continue correcting acidosis.

⭐ To prevent cerebral edema, the rate of blood glucose fall should not exceed 100 mg/dL/hr. Closely monitor neurological status.

Pediatric DKA Management Algorithm

Monitoring & Complications - The Brain Watch

Hourly: Neuro-obs (GCS), vitals, & capillary blood glucose.
2-4 Hourly: Venous blood gas & serum electrolytes (esp. K+).
Strict I/O Charting: Meticulously track fluid balance.

⚠️ Cerebral Edema

Highest Risk: 4-12 hours after starting treatment.
Red Flags: Headache, slowing heart rate, irritability, ↓GCS, incontinence.
Management Protocol:
- Elevate head of bed.
- Reduce IV fluid rate by ⅓.
- Mannitol: 0.5-1 g/kg IV over 20 min.
- 3% Hypertonic Saline: 5-10 mL/kg over 30 min.

⭐ For any acute neurological deterioration, presume cerebral edema until proven otherwise. The mortality rate is 20-25%.

Risk factors for DKA-related cerebral edema

High‑Yield Points - ⚡ Biggest Takeaways

Diagnosis: Blood glucose >200 mg/dL, venous pH <7.3 or HCO3 <15 mmol/L, and ketonemia.

Initial fluid: 10-20 ml/kg of 0.9% saline. Avoid rapid correction to prevent cerebral edema.

Insulin: Start 0.1 U/kg/hr infusion after initial fluid resuscitation. No IV bolus.

Cerebral edema: The most feared complication. Watch for headache, altered sensorium, and bradycardia. Treat with Mannitol.

Potassium: Add to IV fluids once urine output is confirmed and K+ is <5.5 mEq/L.

Glucose: Add dextrose to fluids when blood glucose falls to ~250 mg/dL.