What is the typical initial management step for a patient presenting with suspected DKA in the emergency department?

• A. Begin isotonic saline hydration and monitor electrolytes; initiate insulin therapy per protocol after assessing potassium status
• B. Immediately start insulin without fluids
• C. Give bicarbonate only
• D. Withhold treatment until lab results

Answer: (A)

The key step is to start aggressive IV hydration with isotonic saline to restore intravascular volume and perfusion, while you monitor electrolytes and glucose. In DKA, total body potassium is depleted even if serum potassium looks normal, so insulin therapy must be timed with potassium status. If the potassium is at or above about 3.3 mEq/L, you can begin insulin therapy per protocol after fluids. If potassium is below 3.3, you should first correct potassium (hold insulin) and only start insulin once K+ is safely above that threshold. Bicarbonate is reserved for unusually severe acidemia and is not routine. Don’t delay treatment waiting for labs; begin fluids now and adjust the plan as lab results return.