شاب عمره ١٩ سنة معروف بالسكري النوع الأول، عنده التهاب حلق من يومين فأوقف الإنسولين لأنه لا يأكل. جاء بقيء وألم بطن وتنفس عميق سريع ورائحة فم فواكه. السكر ٤٨٦، والـpH ٧٫١٢، والبيكربونات ٩، والكيتونات مرتفعة، والضغط ٩٨/٥٨، والنبض ١٢٤. ما الإجراء الأول بعد تقييم مجرى الهواء؟

A 19-year-old with type 1 diabetes has had a sore throat for two days and stopped insulin because he is not eating. He presents with vomiting, abdominal pain, deep rapid breathing and fruity breath. Glucose 486 mg/dL, pH 7.12, bicarbonate 9, ketones high, BP 98/58, HR 124. After assessing the airway, what is the first action?

1. Routine IV bicarbonate to correct the acidosis quickly
2. Adequate IV fluids with normal saline
3. A large subcutaneous insulin dose immediately before any fluids
4. 5% dextrose because he has not eaten for two days

Answer: B) Adequate IV fluids with normal saline. In DKA fluid replacement comes first because dehydration is severe, followed by a continuous IV insulin infusion once potassium is checked. Bicarbonate is not routine, and dextrose is added when glucose falls to about 250.