Emergency department case presentation of HHS

1. CASE PRESENTATION
EMERGENCY DEPARTMENT
PRAVEEN RK

2. • Name : XYZ
• Age: 43y
• Sex : M
• OP no : *********
• Date : 07/05/19
• Time : 9:45 PM
• Source of history : Wife
• MOA : Private

3. Brief targeted history
• Inappropriate noise and involuntary movement involving all 4 limbs at
around 9 pm.

4. Airway Evaluation
• Patent

5. Breathing Evaluation
• RR : 28/min
• Spo2 : 88%
• Breathing pattern : Abdominothoracic
• Chest rise : Normal
• Accessory muscle use : Nil
• Auscultation: NVBS

6. Circulation Evaluation
• HR : 100/min
• BP : 200/140 mmhg
• Rhythm : Regular
• Heart sound : S1S2+
• Peripheral pulse : Present
• Capillary refill : Normal
• Hydration : Normal
• Temperature: 98.6F
• CBG : 547mg/dl

7. Disability and Deformity
• GCS : E3 V2 M5
• Pupil : Reactive

8. Past History
• K/C
• DM , stopped treatment
• HTN
• H/O Kidney transplantation

9. General Physical Examination
• No pallor, icterus, cyanosis, clubbing, lymphadenopathy, edema

10. Respiratory System
• Chest expansion +
• Auscultation : B/L NVBS

11. Cardiovascular System
• Heart sound : S1 S2 +
• No murmur

12. Abdomen
• Surgical scar present on RIF for Kidney transplantation
• Soft nontender

13. Central Nervous System
• Not oriented
• No FND

14. Investigations
• ABG :
• Lactic acidosis
• pH 7.4
• HCO3- 21.7 mmol/L

15. • ECG : LVH with strain
• Blood RE : Normal
• Urine RE : Normal

16. Differential diagnosis
• Hyperglycemic Hyperosmolar State
• Status Epilepticus
• Hypertensive encephalopathy

17. Plan of Care
• IV access - 18G & 20G
• IVF NS 500mL Bolus
• Inj FOSOLIN 1350mg in 100mL NS over 1/2 hr
• Inj EMESET 8mg IV stat
• Inj LORAZEPAM

18. • ET intubation
• Indication : Status epileptics, vomiting and impending aspiration
• Inj MIDAZ 2mg + Inj FENTANYL 100mg +Inj SCOLINE 100mg IV stat
• Ryles tube with continuous aspiration
• Bladder catheterisation
• IVF NS 500mL Bolus 100mL per hr
• Inj PAN 40 mg IV OD

19. • Inj FENTANYL 300mcg +Inj MIDAZ 10mg in 50ml dilution @ 5ml/hr
• Inj VECURONIUM 4mg IV stat
• Head end elevated 30o
• Repeat CBG : 564mg/dl
• CBG hourly
• Inj H Actrapid @ 8U/hr infusion (if K+ >3.5)
• Admission in MICU

20. Consultant Notes
• Inj CEFTRIAXONE 1.5g IV BD
• Inj EPTOIN 100mg IV TID
• Inj H. Actrapid (SOS) sliding scale
• GRBS Q4h monitoring
• Inj PAN 40 mg IV OD
• Inj EMESET 4mg IV TID
• T. CARDIVAS 6.25mg 1-0-0
• T. ECOSPIRIN 150mg 0-1-0

21. • T. CLOPIDOGREL 150mg 0-1-0
• T. ATORVASTATIN 40mg 0-0-1
• C. PANGRAF 1.25mg (morning) 1mg (evening)
• T. CLINIDIPINE 10mg BD

22. Hyperglycaemic Hyperosmolar State
• HHS is characterised by progressives hyperglycaemia and
hyperosmolarity typically found in a debilitated patient with poorly
controlled or undiagnosed type 2 DM, limited access to water and
commonly a precipitating illness.
• Factors for development of HHS
• Insulin resistance/ deficiency
• Inflammatory state with markedly raised cytokines
• Osmotic diuresis followed by impaired renal excretion of glucose

23. • Lack of severe ketoacidosis in HHS
• Higher level of endogenous insulin inhibits lipolysis
• Lower levels of counterregulatory stress hormones
• Inhibition of lipolysis by hyperosmolar state

24. • Clinical features
• Usually elderly with comorbidities
• Nonspecific complaints
• Weakness, anorexia, fatigue, dyspnea, chest or abdominal pain
• Underlying systemic illness
• Antipsychotics or lithium are risk factors

25. • Physical examination
• Clinical signs of volume depletion
• Poor skin turgor, dry mucous membrane, sunken eyes, hypotension
• Normothermia or hypothermia

26. • Diagnosis
• Serum glucose >600mg/dl (33.3 mmol/L)
• Elevated calculated plasma osmolality of >315 mOsm/kg (315 mmol/kg)
• Serum bicarbonate > 15 mmol/L
• Arterial pH >7.3

27. • Treatment

28. • Differential diagnosis
• DKA
DKA HHS
Plasma glucose > 250 mg/dl >600 mg/dl
Serum bicarbonate < 18 mmol/L > 15 mmol/L
Urine acetoacetate + -
Serum ketones + -
Serum osmolality Variable > 320 mOsm/kg
Anion gap > 12 mmol/L < 12 mmol/L
Arterial or venois pH < 7.3 > 7.3

29. THANK YOU