You would recognise hyperkalemia a mile away.

You remember you should not be giving more than 40mmol KCl per 1 litre (which you weren’t doing in this case ), and this amount of potassium (40mmol KCl) must not flow into the veins faster than over 1 hour. Potassium is not given in the first bag of fluids in DKA anyway, and whenever potassium is used IV, rapid changes in the concentration of potassium are avoided by sticking to these limits. You remember that the lethal injection for executions works by infusing potassium IV at faster rates than these limits.

You would normally initiate management exactly like this model FY1:

However, in this case the patient needs a fixed rate insulin infusion anyway for her likely DKA. You start an insulin infusion which should bring the potassium down through two mechanisms:

a) intracellular shift of potassium as a direct action of insulin

b) by halting ketone production, and therefore resolving the acidosis (and acidosis tends to cause hyperkalemia)

The Med SpR appears on the scene with his hands on his hips and a face that says “Relax kids, daddy’s here”. |

Score: 3/10 – the amount of potassium given at that rate did more harm than good, but you recognised it and managed it. It may be worth refreshing DKA diagnosis and management.