What is the appropriate management for a patient presenting with severe dehydration, hyperglycemia, and significant ketonuria, accompanied by symptoms of nausea, vomiting, and chest pain?

Management of Suspected Diabetic Ketoacidosis (DKA)

This 29-year-old male requires immediate hospitalization for intravenous fluid resuscitation, insulin therapy, and electrolyte management, as he presents with classic signs of diabetic ketoacidosis—significant ketonuria (4+), severe dehydration (specific gravity 1.030), inability to tolerate oral intake, nausea, vomiting, and chest pain—which constitutes a life-threatening emergency requiring immediate medical intervention to prevent complications and death. 1

Immediate Assessment Required

This patient cannot be managed at home and requires emergency department evaluation because:

• Inability to tolerate oral hydration is an absolute indication for immediate medical attention 1
• The combination of 4+ urine ketones with inability to eat or drink for 3-4 days indicates moderate to severe DKA 1, 2
• Specific gravity of 1.030 confirms severe dehydration requiring intravenous fluid replacement 3
• Chest pain in the setting of DKA may indicate a precipitating cardiac event (myocardial infarction) or metabolic stress that must be evaluated 3, 4

Clinical Presentation Consistent with DKA

This patient demonstrates the classic DKA presentation that typically develops over hours to days 2:

• Nausea and vomiting are prominent gastrointestinal features of DKA 2
• Severe dehydration evidenced by high urine specific gravity and inability to tolerate fluids 2
• Significant ketonuria (4+) indicates active ketoacid production 1, 2
• Heart rate of 98 may represent compensatory tachycardia for dehydration 3

The patient is described as alert (not obtunded), which is typical for DKA, unlike hyperosmolar hyperglycemic state where altered mental status is common 2. However, any patient unable to tolerate oral intake requires immediate inpatient treatment regardless of mental status 1.

Hospital-Based Treatment Protocol

1. Fluid Resuscitation (First Priority)

Begin immediate fluid resuscitation with 0.9% sodium chloride solution at 15-20 mL/kg/hour during the first hour to restore circulatory volume and tissue perfusion 3, 4. For this patient:

• Calculate approximately 1-1.5 liters in the first hour for an average adult male 3
• Continue fluid replacement to correct estimated deficits within the first 24 hours 3
• The severe dehydration indicated by specific gravity 1.030 suggests substantial volume depletion requiring aggressive initial resuscitation 3

2. Insulin Therapy

Administer intravenous insulin bolus of 0.1 units/kg body weight, followed by continuous infusion at 0.1 units/kg/hour 3, 4. This approach:

• Reverses ketoacid production by the liver 5
• Must be continued until the anion gap normalizes, not just until glucose normalizes 5
• Requires adding dextrose to IV fluids once glucose falls to 250 mg/dL to prevent hypoglycemia while continuing insulin to clear ketones 6, 5

3. Electrolyte Management (Critical)

Monitor potassium levels closely as total body potassium deficits are common despite potentially normal or elevated initial serum levels due to dehydration 3:

• Begin potassium replacement after serum levels fall below 5.5 mEq/L, assuming adequate urine output 3
• Failure to recognize total-body potassium depletion may lead to fatal cardiac arrhythmia 5
• Draw blood every 2-4 hours to determine serum electrolytes, glucose, blood urea nitrogen, creatinine, osmolality, and venous pH 3, 4

4. Monitoring Requirements

Monitor blood glucose at least every 2-4 hours throughout treatment 3, 4:

• Check arterial or venous pH, bicarbonate, and anion gap to assess resolution of ketoacidosis 1, 2
• Continue insulin infusion until anion gap normalizes, even if glucose is controlled 5
• Watch for signs of cerebral edema (though rare in adults): headache, altered mental status, or neurological deterioration 7

5. Identify Precipitating Cause

The chest pain in this patient mandates evaluation for myocardial infarction or other cardiac events as a precipitating factor 3, 4:

• Obtain ECG and cardiac biomarkers 3
• Infection is the most common precipitating factor in DKA development 3
• Search for other triggers: medication nonadherence, new diabetes diagnosis, or other acute illness 8, 9

Critical Pitfalls to Avoid

Do not attempt outpatient management when the patient cannot tolerate oral hydration 1. The 2025 American Diabetes Association guidelines explicitly state that inability to tolerate oral intake is an absolute contraindication to home management 1.

Do not stop insulin infusion prematurely 5. Ketogenesis may be reversed inadequately unless insulin treatment continues until the anion gap normalizes, not just until glucose normalizes 5.

Do not overlook potassium replacement 3, 5. Despite potentially normal initial levels, total body potassium is depleted and requires aggressive replacement once levels fall below 5.5 mEq/L 3.

Do not dismiss the chest pain 3, 4. This symptom requires cardiac evaluation as myocardial infarction can both precipitate and complicate DKA 3.

Transition to Subcutaneous Insulin

Successful transition from intravenous to subcutaneous insulin requires administration of basal insulin 2-4 hours before the intravenous insulin is stopped to prevent rebound hyperglycemia 3, 4:

• This transition should only occur after resolution of ketoacidosis (normalized anion gap) 5
• Target pre-meal glucose <140 mg/dL and random glucose <180 mg/dL for non-critically ill patients 4

Prognosis and Expected Outcomes

The overall mortality for DKA in adults is <1% when recognized and treated appropriately 9. However, delayed recognition or inadequate treatment can lead to death from dehydration, electrolyte abnormalities, or underlying precipitating causes 6, 9.