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
- Primary survey and vitals; IV access and monitors.
- Focused history/physical; identify red flags and likely etiologies.
- Order system-appropriate labs and imaging (see Investigations).
- Initiate guideline-based empiric therapy (see Pharmacology).
- 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.
Epidemiology / Risk Factors
- Diabetes and endocrine disorders depending on topic
Investigations
| Test | Role / Rationale | Typical Findings | Notes |
|---|---|---|---|
| BMP | Electrolytes/anion gap | Derangements | |
| Ketones (if DKA) | Ketoacidosis | Positive | |
| ABG/VBG | Acid–base status | Acidosis/alkalosis |
DKA vs HHS (Typical)
| Parameter | DKA | HHS |
|---|---|---|
| Glucose | >250 | >600 |
| pH | ≤7.30 | >7.30 |
| Ketones | Marked | Minimal/absent |
| Effective osmolality | Variable | >320 mOsm/kg |
Pharmacology
| Medication | Mechanism | Onset | Role in Therapy | Limitations |
|---|---|---|---|---|
| Isotonic fluids | Volume expansion | Immediate | Primary therapy; correct dehydration | Fluid overload |
| Regular insulin (IV) | Antihyperglycemic | Minutes | After initial fluids | Hypoglycemia |
| Potassium repletion | Electrolyte | Hours | As needed based on levels | Arrhythmia risk |
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.
Notes
Use balanced crystalloids when possible; consider hypotonic saline if severe hypernatremia. Elderly and CKD patients require careful fluid/insulin titration.