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Question 1

What is HHS?

Answer 1

-Severe uncorrected hyperglycaemia
-Usually occurs in the elderly, T2DM
-Slow onset - takes days to weeks to develop
-DKA and HHS may occur simultaneously

Question 2

What is the pathophysiology behind a hyperglycaemic hyperosmolar state (HHS)?

Answer 2

-Hyperglycaemia –> increased urination and loss of Na+ and K+
-Severe volume depletion raises serum osmolarity resulting in hyper-viscosity of the blood
-Patient may appear only mildly dehydrated due to hypertonicity

Question 3

What causes HHS?

Answer 3

-Sugary food
-Steroids
-Non-compliance with diabetes treatment
-Infection
-Acute illness

Question 4

How does HHS present?

Answer 4

-Fatigue, weakness
-N+V
-Headaches
-Papilloedema
-Dehydration
-Hypertension, tachycardia
-Thirst, polyuria, urgency
-Weight loss
-Rashes
-SOB
SIGNS
-Signs of infection, sweet-smelling breath, hypovolaemic

Question 5

What are the diagnostic criteria for HHS?

Answer 5

-Hypovolaemia
-Raised plasma osmolarity >320
-High glucose >30mmol/L

Question 6

How should you examine a patient presenting with their first seizure?

Answer 6

-Full CNS examination
-GCS
-Fundoscopy
-CV examination (exclude syncope)
-Beware of Todd’s Paresis - focal deficit / hemiparesis persisting for up to 24h post seizure - indicates likely structural lesion

Question 7

What are possible non-epileptic causes of a new seizure?

Answer 7

-Drug / alcohol use, withdrawal states
-Hypoglycaemia
-Arrhythmia
-Head injury, stroke / TIA, SAH
-Liver disease
-Infection
-Metabolic disturbances

Question 8

How would you investigate someone presenting with a first seizure?

Answer 8

-Glucose, FBC, U+Es
-ECG, SpO2
-Blood cultures if pyrexial
-CXR if chest signs
-Urine dip (PT if WCBA)
-Brain imaging

Question 9

How would you manage someone with seizures?

Answer 9

A-E
-Maintain airway using recovery position (?anaesthetist)
-Most self-limiting
-If prolonged –> Benzos eg:
–Rectal diazepam 10-20mg
–Buccal midazolam
–IV lorazepam
Discharge
-If normal cardio and neurological exams + normal ECG and electrolytes
-Cannot drive

Question 10

What is important to ask in the history of a known epileptic?

Answer 10

-Change from seizure pattern?
-Possible causes of poor seizure control?
-Compliance to meds?
-Recent illness or infection?
-Alcohol and drug use?
-Check anticonvulsant level if ?toxicity or ?poor compliance

Question 11

What is status epilepticus and how does it present?

Answer 11

-Continuous generalised seizure lasting >30 mins without regaining consciousness
-Cerebral damage increases with duration
-May start as tonic-clonic and then diminish to coma and minimal twitching

Question 12

What can cause status epilepticus and what complications can result from it?

Answer 12

Causes:
-Cerebral infection
-Trauma
-CVD
-Toxic / metabolic disturbances
-Childhood febrile seizures
Complications:
-Hypoglycaemia
-Pulmonary HTN
-Pulmonary oedema
-Increased ICP

Question 13

What drugs would you consider to control status epilepticus?

Answer 13

-Lorazepam IV (max 4mg)
-Buccal midazolam or rectal diazepam if no IV access
-Phenytoin 20mg/kg IV (max 2g)
-Thiamine if alcohol abuse or malnutrition
-Magnesium sulfate IV if pregnant