Assess airway, breathing, circulation, mental status, and vital signs
Obtain bedside glucose, ketones, electrolytes, venous blood gas, anion gap, renal function, and serum osmolality
Start isotonic intravenous fluids
Give 0.9% saline or balanced crystalloid initially
Continue fluid resuscitation based on hemodynamics, corrected sodium, and urine output
Start intravenous regular insulin after potassium is confirmed safe
Use a continuous insulin infusion
Replace potassium before or with insulin if potassium is low or normal
Hold insulin and give potassium first if potassium is severely low
Monitor potassium, glucose, bicarbonate, anion gap, and venous pH frequently
Add dextrose to IV fluids when glucose falls to target range while continuing insulin
Treat the underlying cause
Give antibiotics if infection is suspected or confirmed
Evaluate for missed insulin, myocardial infarction, stroke, pancreatitis, or other triggers
Replace phosphate only if severe hypophosphatemia or symptoms are present
Replace magnesium if low
Monitor for cerebral edema, arrhythmias, and fluid overload
Continue insulin until the anion gap closes and acidosis resolves
Transition to subcutaneous insulin with overlap before stopping the infusion
Provide diabetes education and sick-day instructions before discharge