Hyperglycemic Emergencies Practice Exam: Diabetes Chapter 15

Diabetic Ketoacidosis (DKA) and Hyperosmolar Hyperglycemic State (HHS) are critical, life-threatening complications that demand rapid assessment and precise intervention. This exam tests your ability to navigate the 2018 Clinical Practice Guidelines to effectively diagnose these conditions, manage electrolyte imbalances, and safely resolve hyperglycemia.

Key Concepts Covered in This Exam:

Diagnosis & Differentiation: Distinguishing between DKA and HHS based on arterial pH, serum bicarbonate, anion gap, and plasma osmolality.
Precipitating Factors: Identifying common triggers such as infection, insulin omission, myocardial infarction, and new-onset diabetes.
Treatment Protocol: Mastering the “order of operations” for management: prioritizing fluid resuscitation (restoring ECFV) and potassium correction before insulin administration.
Electrolyte Safety: Understanding the critical importance of monitoring potassium levels to prevent fatal arrhythmias during insulin therapy.
Special Situations: Recognizing “euglycemic DKA” (normal or mildly elevated blood glucose with ketoacidosis), particularly in patients taking SGLT2 inhibitors or during pregnancy.

1. Case: A patient in DKA has a serum potassium of 3.0 mmol/L at presentation. What is the most appropriate management?

Withhold insulin until potassium replacement has restored plasma potassium to ≥3.3 mmol/L
Give IV bicarbonate to correct the acidosis first
Start insulin at double the usual rate
Start insulin infusion immediately and add potassium to fluids

2. Case: A diabetes educator is developing sick-day management education. Which intervention has been shown to reduce emergency room visits and hospitalizations in young people with type 1 diabetes?

Increasing insulin doses during illness
Sick-day management that includes capillary beta-hydroxybutyrate monitoring
Avoiding all carbohydrates during illness
Stopping all fluids during illness

3. What percentage of people with HHS present with infections as a precipitating factor?

70% to 80%
20% to 30%
40% to 60%
10% to 20%

4. Which neurological presentations can occur in HHS that may resolve once osmolality returns to normal?

Permanent hemiparesis
Peripheral neuropathy
Autonomic dysfunction
Seizures and stroke-like state

5. Case: A 72-year-old patient with type 2 diabetes is hospitalized with HHS. In-hospital mortality data shows mortality varies significantly by age. What is the approximate mortality rate in people over 75 years?

16%
<1%
10%
5%

6. Case: A clinical team is managing a patient with HHS. When considering mortality, approximately what percentage of deaths occur in the first 48 to 72 hours?

About 75%
About 35%
About 20%
About 50%

7. What type of ketone testing is preferred according to the guidelines?

Blood ketone testing is preferred over urine testing
Both are equally accurate
Neither is recommended
Urine ketone testing is preferred

8. What is the incidence of DKA in individuals with type 1 diabetes?

0.5 to 1.0 per 1,000 patient-years
10.0 to 15.0 per 1,000 patient-years
4.6 to 8.0 per 1,000 patient-years
2.0 to 4.0 per 1,000 patient-years

9. Case: A diabetes educator is reviewing the evidence on phosphate therapy in DKA. What does the current evidence support?

Phosphate should be given before potassium
Phosphate therapy prevents rhabdomyolysis in DKA
Routine phosphate therapy is recommended for all DKA patients
There is currently no evidence to support routine phosphate therapy for DKA

10. Case: A patient with DKA has been treated with IV fluids and insulin. Anion gap has normalized. What indicates resolution of ketoacidosis?

Blood glucose <10 mmol/L
Resolution of nausea only
Patient reports feeling better
Normalization of the plasma anion gap

11. Case: A 65-year-old patient with HHS has a plasma osmolality of 340 mOsm/kg. At what rate should plasma osmolality be lowered to reduce the risk of cerebral edema?

No faster than 10 mmol/kg/h
No faster than 3 mmol/kg/h
No faster than 5 mmol/kg/h
No faster than 1 mmol/kg/h

12. Case: A 28-year-old patient with type 1 diabetes presents with nausea, vomiting, and abdominal pain. Blood glucose is 22 mmol/L, arterial pH is 7.25, and serum bicarbonate is 12 mmol/L. What is the initial fluid therapy recommendation?

IV Ringer’s lactate at 1000 mL/h
IV 0.9% sodium chloride at 500 mL/h for 4 hours
IV dextrose 5% at 500 mL/h
IV 0.45% sodium chloride at 250 mL/h

13. A patient with type 2 diabetes on an SGLT2 inhibitor presents with nausea and vomiting. Blood glucose is 11 mmol/L. Should DKA be considered?

No, SGLT2 inhibitors protect against DKA
No, blood glucose is too low for DKA
Only if the patient has type 1 diabetes
Yes, SGLT2 inhibitors can cause DKA with normal or mildly elevated blood glucose

14. What is the typical potassium deficit range in DKA?

1 to 2 mmol/kg
6 to 8 mmol/kg
9 to 12 mmol/kg
2 to 5 mmol/kg

15. What is the preferred term for the condition previously known as ‘hyperosmolar nonketotic coma’ (HONKC)?

Diabetic coma
Non-ketotic hyperglycemia
Hyperosmolar hyperglycemic state
Hyperglycemic crisis syndrome

16. What plasma glucose level is typically seen in HHS?

≥28.0 mmol/L
≥14.0 mmol/L
≥20.0 mmol/L
≥34.0 mmol/L

17. What is the typical sodium deficit in DKA?

1 to 3 mmol/kg
7 to 10 mmol/kg
12 to 15 mmol/kg
4 to 6 mmol/kg

18. What plasma glucose level is typically diagnostic for DKA?

≥7.0 mmol/L
≥20.0 mmol/L
≥10.0 mmol/L
≥14.0 mmol/L

19. What plasma osmolality level is typically seen in hyperosmolar hyperglycemic state (HHS)?

>350 mOsm/kg
>280 mOsm/kg
>300 mOsm/kg
>320 mOsm/kg

20. What is the recommended beta-hydroxybutyrate threshold that warrants further testing for DKA?

>0.5 mmol/L
>1.0 mmol/L
>2.0 mmol/L
>1.5 mmol/L

21. Case: A patient on CSII (insulin pump) therapy presents with DKA. What should be considered about pump therapy and DKA risk?

CSII therapy eliminates DKA risk
CSII therapy is a possible risk factor for DKA
CSII therapy reduces DKA risk by 50%
CSII therapy is contraindicated in patients with prior DKA

22. Case: During DKA treatment, plasma glucose drops to 14.0 mmol/L but ketoacidosis has not resolved. What is the appropriate action?

Add IV dextrose while maintaining insulin infusion to resolve ketosis
Reduce insulin infusion rate by 50%
Stop insulin infusion
Switch to subcutaneous insulin

23. Case: A clinical team is debating whether to use an initial insulin bolus in treating adult DKA. Based on the evidence, what is the most accurate statement?

There is no conclusive evidence supporting the use of an initial insulin bolus in adults
Bolus insulin is contraindicated in all cases
An initial bolus is always required for effective treatment
Bolus insulin has been proven superior to infusion alone

24. Case: A diabetes educator is teaching a patient about sick-day management. According to the guidelines, when should a person with type 1 diabetes check for ketones?

Only when blood glucose is above 20 mmol/L
Only if vomiting occurs
When blood glucose levels remain over 14 mmol/L before meals
Only when admitted to hospital

25. What are the typical diagnostic criteria for diabetic ketoacidosis (DKA) according to Diabetes Canada guidelines?

Arterial pH ≤7.3, serum bicarbonate ≤15 mmol/L, anion gap >12 mmol/L with positive ketones
Arterial pH ≤7.5, serum bicarbonate ≤20 mmol/L, anion gap >8 mmol/L
Arterial pH ≤7.4, serum bicarbonate ≤18 mmol/L, anion gap >10 mmol/L
Arterial pH ≤7.1, serum bicarbonate ≤10 mmol/L, anion gap >20 mmol/L

26. When should potassium supplementation typically be started in a patient with DKA who presents with hyperkalemia?

Immediately upon presentation
Once serum potassium falls to <5.0 to 5.5 mmol/L and diuresis is established
Only if ECG changes are present
After ketoacidosis has resolved

27. Case: A 45-year-old patient presents with DKA. ECG shows peaked T waves. What should be suspected and addressed?

Hyperkalemia
Hypomagnesemia
Hypokalemia
Hypocalcemia

28. What target plasma glucose range should be maintained once IV dextrose is started during DKA treatment?

8.0 to 10.0 mmol/L
6.0 to 8.0 mmol/L
12.0 to 14.0 mmol/L
16.0 to 18.0 mmol/L

29. Case: A patient in DKA is in shock with blood pressure of 80/50 mmHg. What is the recommended initial fluid administration rate?

250 mL/h
1 to 2 L/h
3 to 4 L/h
500 mL/h

30. Case: A pregnant woman at 28 weeks gestation presents with symptoms of DKA. Her blood glucose is 12 mmol/L. What is important to consider?

Pregnant women with DKA typically present with lower plasma glucose levels
DKA can be ruled out because blood glucose is below 14 mmol/L
Only ketone testing is needed, not blood gas analysis
Pregnancy protects against DKA

31. Case: A patient with type 1 diabetes presents with DKA. Venous blood gas shows pH 7.18. How does this compare to arterial pH?

Venous pH cannot be used in DKA assessment
Venous and arterial pH are identical
Venous pH is typically 0.1 to 0.2 higher than arterial pH
Venous pH is typically 0.015 to 0.03 lower than arterial pH

32. Case: A patient presents with suspected DKA. Serum ketone testing is negative. What should be considered?

Beta-hydroxybutyrate levels should be measured
Switch diagnosis to HHS
DKA is definitively ruled out
Discharge the patient home

33. According to the guidelines, at what arterial pH level may sodium bicarbonate therapy be considered in DKA?

pH ≤7.0
pH ≤7.2
pH ≤7.1
pH ≤7.3

34. What is ketosis-prone diabetes (KPD) and what are its characteristics?

Individuals who present with DKA but don’t have typical type 1 diabetes features
Type 2 diabetes with insulin resistance only
Gestational diabetes with ketone production
A form of type 1 diabetes with complete beta cell destruction

35. After hypotension has been corrected in DKA, what IV fluid is typically used?

Lactated Ringer’s solution
0.9% sodium chloride continued
Dextrose 10%
0.45% sodium chloride (with potassium chloride)

36. What is the recommended initial rate of intravenous insulin infusion for treating DKA in adults?

0.2 units/kg/h
0.1 units/kg/h
0.15 units/kg/h
0.05 units/kg/h

37. Why are capillary blood glucose (CBG) measurements considered unreliable in severe DKA?

CBG readings are always higher than plasma glucose
CBG measurements are unreliable in the setting of severe acidosis
CBG meters cannot measure high glucose levels
CBG meters are not approved for hospital use

38. Which of the following is NOT a recognized risk factor for DKA?

Myocardial infarction
Cocaine use
High dose metformin use
Insulin omission

39. A patient presents with DKA and has mixed acid-base disorders due to associated vomiting. How might this affect the serum bicarbonate level?

Bicarbonate testing becomes unreliable
Bicarbonate will be lower than expected
Bicarbonate is not affected by vomiting
Vomiting will raise the bicarbonate level

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