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Emergency Medicine > HHS > Flashcards

HHS Flashcards

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Royal College: Emergency Medicine flashcards
1
Q

How would you calculate serum osmolarity?

A

2x(K+ + Na+) + Urea + Glucose

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2
Q

What are differences between HHS and DKA?

A
  • More hyperglycaemic
  • More Dehydrated
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3
Q

Why do people with HHS not normally develop ketones?

A

Still some insulin sensitivity, which suppresses lipolysis enough to stop ketone production

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4
Q

Why would you prophylactically anti-coagulate someone with HHS?

A

They are very dehydrated, meaning they are at significantly increased risk of developing DVTs and PEs

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5
Q

What is hyperosmolar hyperglycaemic state?

A

This condition, in which severe hyperglycaemia develops without significant ketosis, is the metabolic emergency characteristic of uncontrolled type 2 diabetes.

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6
Q

What can cause HHS in someone with diabetes?

A

Inadequate insulin/non compliance (21-41%)
Acute illness

  • Infection (32-60%)
  • CVA
  • MI
  • Pancreatitis

Others

  • Endocrine
  • Drugs - B-blockers, antipsychotics, steroids, immunosuppressants
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7
Q

What is the pathophysiology of HHS?

A

https://www.youtube.com/watch?v=QRLZwXL6w1c

A relative insulin deficiency leads to a serum glucose that is usually higher than 33 mmol/L, and a resulting serum osmolarity that is greater than 320 mOsm. This leads to excessive urination (more specifically an osmotic diuresis), which, in turn, leads to volume depletion and hemoconcentration that causes a further increase in blood glucose level.

Ketosis is absent because the presence of some insulin inhibits hormone-sensitive lipase mediated fat tissue breakdown.

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8
Q

What are symptoms of HHS?

A
  • Thirst
  • Polyuria
  • Polydipsia
  • Stupor/Coma
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9
Q

What are signs of HHS?

A

Signs of excessive dehydration

  • Tachycardia
  • Hypotension
  • Sunken eyes
  • Dry mucus membranes

Reduced consciousness

Evidence of occlusive events

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10
Q

Why can individuals with HHS present with reduced consciousness?

A

Increased plasma osmolarity

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11
Q

What plasma osmolarity is usually seen in HHS?

A

>320 mOsm/kg

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12
Q

How hyperglycaemic are people who present with HHS?

A

>30 mmol/L

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13
Q

What tests would you do in someone presenting with symptoms of HHS?

A
  • Bedside - urine diptick, cap glucose/ketones, ECG
  • Bloods - FBC, U+E’s CRP, Serum osmolality, VBG/ABG, Cap and lab glucose, blood cultures
  • Imaging - CXR
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14
Q

Why is serum sodium often low in HHS?

A

Hyperglycaemia induces osmotic movement of water from cells into intravascular space, causing dilution of sodium

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15
Q

Why would you perform a CXR in HHS?

A

Look for a precipitant

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16
Q

What are the principles to managing someone with HHS?

A

Basic principles as per DKA

  • I.V. fluids
    • Rapid if shocked
    • More gradual than DKA if not shocked
  • I.V. insulin
  • Potassium

Address underlying precipitant
DVT prophylaxis

17
Q

What rate would you give insulin initially in HHS?

A

3 units/hr (0.05units/kg/hr)

18
Q

What would you do within the first hour of managing someone with HHS?

A
  • Initial investigations - FBC, U+E, VBG, Blood glucose, lactate
  • Fluids - NaCl 0.9% 1L/hr
  • Consider Insulin - 3 units/hr
    • Only if glucose is not coming down on fluid therapy alone
  • Monitoring
19
Q

What would you reduce the hourly rate of fluids to in hours 2-4 in management of HHS?

A

500 mls/hr NaCl 0.9%

20
Q

What would you do if BG did not decrease within the first couple of hours of insulin treatment in someone with HHS?

A

Increase insulin treatment

21
Q

If blood glucose fell below 14 mmol/L when managing someone with HHS, what would you do?

A

10% dextrose + KCL at 100 ml/hr

28
Q

When would you consider stopping IV insulin therapy?

A

When patient is stable and eating, and can digest antidiabetic medications

29
Q

What are the main criteria for the diagnosis of HHS?

A
  • Glucose > 11 mmol/L
  • Plasma Osmolartiy >320 mOsm/L
  • Absence of ketosis
30
Q

Why should metformin be stopped in someone with HHS?

A

Can cause a metabolic acidosis

31
Q

When would you consider starting someone on IV insulin in HHS?

A

http://oscestop.com/Diabetic%20Emergencies.pdf

If, after the first hour of management of HHS with fluids, blood glucose has not come down

32
Q

How would you prophylactically manage risk of VTE in someone with HHS?

A

LMWH

Emergency Medicine (32 decks)

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