Ep 147 HHS Recognition and ED Management

In this podcast, Part 2 of our diabetic emergencies series with Melanie Baimel, Bourke Tillmann and Leeor Sommer, we dive into the recognition and ED management of Hyperglycemic Hyperosmolar State (HHS). We answer questions such as: how does one differentiate DKA from HHS clinically? How do patients with HHS become hyperglycemic, dry and altered? Why is finding and treating the cause or trigger of HHS so important in the ED? How does fluid management differ in HHS from DKA? and many more... Podcast production, sound design & editing by Anton Helman; voice editing by Raymond Cho Written Summary and blog post by Winny Li, edited by Anton Helman October, 2020 Cite this podcast as: Helman, A. Baimel, M, Sommer, L. Tillmann, B. Episode 147 HHS Recognition and ED Management. Emergency Medicine Cases. October, 2020. https://emergencymedicinecases.com/HSS-. Accessed [date] For part 1 of this series on Diabetic Emergencies go to Episode 146 DKA Recognition and ED Management DKA and HHS are two distinct entities that exist on the spectrum of diabetic emergencies. HHS is characterized by the triad of severe hyperglycemia (>33.3 mmol/L or >600 mg/dL), elevated serum osmolality (>320 Osm/kg), and altered level of awareness (LOA). HHS occurs without significant ketoacidosis, the anion gap is variable and patients often present with profound volume depletion. Importantly, HHS can occur concurrently with DKA making the ED diagnosis even more challenging. Differentiating DKA from HHS   How do patients with HHS become severely hyperglycemic, dry and altered? In HHS, there is relative insulin deficiency or resistance, leading to impaired glucose utilization, resulting in severe hyperglycemia and subsequent volume depletion from osmotic diuresis. However, there is sufficient insulin to suppress ketogenesis (thus minimal or no ketones), but not enough to control hyperglycemia. This insidious process permits ongoing osmotic diuresis and progressive volume depletion. Increased counter-regulatory hormones in HHS can also exacerbate this cycle of hyperglycemia and further volume depletion through decreased insulin sensitivity, increased glycogenolysis and gluconeogenesis. This is the reason why patients with HHS often present with a protracted course of illness. In contrast, DKA is a state of absolute insulin deficiency. In order for the body to meet its basic metabolic demands, fatty acid metabolism/ketosis occurs. Patients in DKA often present much sooner in their course of illness as their body cannot tolerate the ketotic/acidotic state. Finding the cause of HHS is of paramount importance The mortality rate of HHS is considerably higher than DKA partly because it more often targets older people with concurrent illnesses. HHS is often precipitated by similar conditions seen in DKA including: infection (pneumonia, UTI, intra-abdominal etc.), insulin deficiency (medication access/non-adherence, intercurrent illness (ACS, PE, stroke etc.) and inadequate hydration. Use the mnemonic 5 “I”s plus drugs if that helps you remember the triggers. Pearl: Mortality in HHS is frequently due to an underlying cause rather than the complications of the condition itself; a thorough investigation for the cause should always be undertaken. Filling the tank: HHS fluid resuscitation Osmotic diuresis from profound hyperglycemia results in significant volume depletion. Fluid resuscitation will help restore intravascular volume and h...