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Suicidal ideation with intoxication and impaired capacity — RCPSC EM MCQ

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HardPsychiatric emergenciesSuicidal ideation with intoxication and impaired capacityRCPSC EM

A 76-year-old with type 2 diabetes has confusion, marked dehydration, glucose 44 mmol/L, serum osmolality 334 mOsm/kg, pH 7.37 and minimal ketones. What is the most appropriate first treatment sequence?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: E — Begin individualized IV fluids and electrolyte monitoring before IV insulin

The best answer is “Begin individualized IV fluids and electrolyte monitoring before IV insulin”. This is hyperosmolar hyperglycaemic state. Initial care prioritizes individualized IV fluid replacement, potassium and electrolyte assessment, and careful osmolality monitoring; IV insulin follows as part of monitored treatment. An initial insulin bolus is not recommended, and fluid restriction, oral rehydration or bicarbonate-first treatment do not correct the severe volume deficit safely.

Reference: Emergency Care BC: Hyperglycemia—Diagnosis and Treatment: https://emergencycarebc.ca/clinical_resource/clinical-summary/hyperglycemia_treatment/