Case 04 · Endocrine
Diabetic ketoacidosis
A 19-year-old with type 1 diabetes stopped her insulin when she was too sick to eat. Now she is drowsy, dry and breathing like she has run a race. Run the first six hours: fluids, fixed-rate insulin, potassium and glucose, with the checks that keep each of them safe.
About this case
What you will practise
Learning objectives
- Confirm DKA and grade its severity with glucose, ketones and a venous gas.
- Give 0.9% saline at the right rate for the first hours.
- Check potassium before insulin, then run fixed-rate insulin at 0.1 units/kg/h.
- Replace potassium by the numbers, and add 10% glucose when glucose falls, keeping the insulin running.
- Monitor hourly and recognise when ketones are not clearing fast enough.
- Treat the precipitant, avoid bicarbonate, and teach the sick-day rules.
Key decisions this case tests
- Insulin first or potassium first?
- The K is 5.8. Does she need potassium?
- Glucose is 230. Do you stop the insulin?
- pH 7.13: bicarbonate or not?
- What made a well-controlled diabetic go into DKA?
Reference basis
- Umpierrez GE et al. Hyperglycemic crises in adults with diabetes: a consensus report (ADA, EASD, JBDS, AACE, DTS). Diabetes Care 2024;47:1257–75.
- Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults (JBDS 02), March 2023.
Content version 1.0 · November 2026 · clinical review pending. See the Clinical content policy.
Before you start
Time runs faster in this case (about 30 simulated seconds per real second), because DKA treatment unfolds over hours. The biochemistry is a simplified teaching model and has not yet been signed off by a clinician.
Visle is for education only and is not medical advice. Follow your hospital’s DKA protocol for real patients.
Ready for another emergency?
Case 03 asks you to spot a krait bite nobody saw, and to ventilate before paralysis reaches the breathing.