Acidotic Andy — Metabolic Acidosis
Kussmaul breathing, fruity breath, pH ↓ · HCO₃⁻ ↓
Andy pulls into the DKA Diner running on empty, orders a fruity milkshake and starts breathing like a steam engine. Every deep breath is his lungs trying to blow the acid out of a body that has already run out of insulin.
Andy's body is drowning in acid. Look for deep, rapid Kussmaul respirations blowing off CO₂, confusion, warm flushed skin and hyperkalemia. Labs: pH < 7.35, HCO₃⁻ < 22, anion gap > 12. Treat the cause first — insulin plus fluids for DKA, not reflexive bicarb.
Read Acidotic Andy's full story →The story arc
The setup
Andy skips two days of insulin during finals week and lives on soda. Cells starve while sugar piles up in the blood outside them.
The turn
By morning he is breathing like a steam engine — deep, tireless, loud — and his roommate smells nail polish on his breath.
The crisis
In triage his pH reads 7.12, his anion gap is 22, and his potassium comes back high even though he has been urinating out potassium for two days.
The save
The nurse hangs isotonic fluids, checks potassium before touching the insulin drip, then titrates and rechecks — no bicarb hero moves.
NCLEX study section — Metabolic Acidosis
What this chapter is testing: the recognition cues, the numbers and the priority action.
Study section: Endocrine & Metabolic
Take this chapter into practice questions on the same topic.