A 22-year-old with type 1 diabetes presents drowsy with glucose 32, ketones 5.6, pH 7.15. Manage this patient.

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This is severe DKA. ABCDE, IV access, catheter for strict fluid balance and hourly cap glucose and ketones. I would start 1L 0.9% saline over the first hour, then a titrated regimen as per the JBDS guideline. Fixed-rate insulin infusion at 0.1 units/kg/hr alongside the patient's usual long-acting insulin. Potassium replacement: nothing if K above 5.5, 40 mmol/L if 3.5-5.5, and senior review with cardiac monitoring if below 3.5. Add 10% dextrose at 125 ml/hr once glucose falls below 14. Investigate the precipitant — infection, non-adherence, MI. Targets are reduction of ketones by 0.5 mmol/L/hr and bicarbonate rise of 3 mmol/L/hr. Diabetes specialist nurse and team referral, VTE prophylaxis, and switch to subcutaneous insulin once eating and ketones below 0.6.

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