Diabetic ketoacidosis (DKA): The Daily PANCE Blueprint
A 19-year-old female with type 1 diabetes mellitus presents to the emergency department with a 2-day history of nausea, vomiting, and diffuse abdominal pain. She appears lethargic, and her parents noted a "fruity" odor on her breath. She missed her last two insulin doses. Vital signs are: HR 120/min, BP 90/60 mmHg, RR 28/min with deep, labored respirations. Mucous membranes are dry. Point-of-care glucose is 450 mg/dL. Which of the following arterial blood gas (ABG) findings is most anticipated?
A. pH 7.50, PaCO2 50 mmHg, HCO3− 30 mEq/L
B. pH 7.25, PaCO2 25 mmHg, HCO3− 12 mEq/L
C. pH 7.00, PaCO2 55 mmHg, HCO3− 24 mEq/L
D. pH 7.38, PaCO2 40 mmHg, HCO3− 22 mEq/L
E. pH 7.55, PaCO2 28 mmHg, HCO3− 25 mEq/L
Answer and topic summary
The answer is B. pH 7.25, PaCO2 25 mmHg, HCO3− 12 mEq/L
This patient presents with classic signs and symptoms of Diabetic Ketoacidosis (DKA), including a history of type 1 diabetes, missed insulin doses, gastrointestinal distress, lethargy, fruity breath (acetone), Kussmaul respirations (deep, labored breathing), tachycardia, hypotension, and hyperglycemia. The expected ABG findings in DKA reflect a metabolic acidosis with respiratory compensation. This involves a low pH (acidemia), a low serum bicarbonate (HCO3−) level (due to buffering of ketoacids), and a low partial pressure of carbon dioxide (PaCO2) as a result of compensatory hyperventilation. Diagnosis of DKA typically includes plasma glucose >250 mg/dL, arterial pH <7.3, serum bicarbonate <18 mEq/L, and the presence of ketones. An elevated anion gap is also characteristic. Management priorities include aggressive intravenous fluid resuscitation, continuous insulin infusion, and careful electrolyte monitoring and replacement, especially potassium.
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