HHS — Diagnosis & Management

Key Points

• Stabilize ABCs; begin targeted evaluation without delaying life-saving therapy.
• Use system-specific risk tools to guide testing and disposition.
• Order high-yield tests first; escalate imaging when indicated.
• Start evidence-based initial therapy and reassess frequently.

Algorithm

1. Primary survey and vitals; IV access and monitors.
2. Focused history/physical; identify red flags and likely etiologies.
3. Order system-appropriate labs and imaging (see Investigations).
4. Initiate guideline-based empiric therapy (see Pharmacology).
5. Reassess response; arrange consultation and definitive management.

Clinical Synopsis & Reasoning

HHS features profound hyperglycemia, hyperosmolality, and dehydration with minimal ketosis; mental status changes are common. Identify triggers (infection, medications, MI, stroke) and quantify osmolar derangements; measure electrolytes frequently to anticipate shifts during therapy.

Treatment Strategy & Disposition

Restore intravascular volume with isotonic fluids, then transition to hypotonic solutions as osmolality corrects; start insulin after initial fluid resuscitation and potassium assessment. Avoid precipitous osmolar changes to reduce cerebral edema risk. Treat triggers, provide VTE prophylaxis, and plan diabetes education and follow‑up; ICU care for severe AMS, shock, or need for continuous insulin titration.

Management Notes

Elderly and comorbid patients require careful fluid management to avoid overload. Avoid dropping osmolality >3 mOsm/kg/h where possible.

Epidemiology / Risk Factors

• Diabetes and endocrine disorders depending on topic

Investigations

Diagnostic Features of HHS

Pharmacology

Prognosis / Complications

• Improves with derangement correction; recurrence if triggers persist

Patient Education / Counseling

• Explain red flags and when to seek emergent care.
• Reinforce medication adherence and follow-up plan.

References

1. Endocrine Society — DKA/HHS — Link