Emergency Medicine · Year 3 · from Emergency Medicine

Case 3: Hyperosmolar Hyperglycemic State (HHS)

Patient Demographics

• Age: 72 years
• Sex: Male
• Occupation: Retired

Chief Complaint

"Found confused at home."

History of Present Illness

EMS brings a 72-year-old male found by his daughter lying in bed, confused and minimally responsive. She last spoke to him 3 days ago and he seemed "a little tired." The patient lives alone and has poorly controlled type 2 diabetes. The home was hot (air conditioning was broken), and daughter noticed many empty soda bottles around.

Initial Assessment

ESI Level: 1 - Altered mental status, critically ill

First Impression:

• Appearance: Obtunded, appears severely dehydrated
• Work of breathing: Normal rate and depth
• Circulation: Dry skin, poor turgor

Vital Signs:

• Heart rate: 116 bpm
• Blood pressure: 88/52 mmHg
• Respiratory rate: 18 breaths/min
• SpO2: 95% on room air
• Temperature: 38.4C
• GCS: 9 (E2V3M4)

Point-of-Care Glucose: "HIGH" (>600 mg/dL - above meter range)

HHS vs. DKA Comparison

Primary Survey

Airway: Patent, not protecting well (GCS 9) Breathing: Normal rate (no Kussmaul - not acidotic) Circulation: Tachycardic, hypotensive, severely dehydrated Disability: Obtunded, GCS 9, no focal deficits, glucose critical Exposure: Dry skin, tenting, concentrated urine

Resuscitation

Immediate Interventions:

1. IV access x2 (difficult - dehydrated)
2. Aggressive fluid resuscitation: NS bolus
3. Continuous cardiac monitoring
4. Labs, including osmolality
5. Urinary catheter (monitor output)

Secondary Survey

SAMPLE History (from daughter):

• Symptoms: Progressive lethargy, confusion
• Allergies: Sulfa
• Medications: Metformin, glipizide (unsure if taking)
• PMH: Type 2 diabetes (poorly controlled), hypertension, CKD
• Last Meal: Unknown
• Events: Found at home after 3 days

Risk Factors:

• Elderly with T2DM
• Limited access to water (debilitated, alone)
• Heat exposure (broken AC)
• Possible infection precipitant

Physical Examination:

• HEENT: Extremely dry mucous membranes, sunken eyes
• Neck: No thyromegaly, no JVD
• Cardiac: Tachycardic, no murmur
• Lungs: Clear (no crackles - severely dehydrated)
• Abdomen: Soft, non-tender
• Skin: Very poor turgor, concentrated urine
• Neuro: Obtunded, moving all extremities, no focal signs

Diagnostic Testing

Labs:

• Glucose: 1,142 mg/dL
• Na: 152 mEq/L (severe hypernatremia)
• K: 4.8 mEq/L
• Cl: 112 mEq/L
• HCO3: 22 mEq/L (near-normal)
• BUN: 86
• Cr: 3.2 (baseline 1.4)
• Serum osmolality: 358 mOsm/kg (severely elevated)
• ABG: pH 7.34, pCO2 36, HCO3 20 (no significant acidosis)
• Beta-hydroxybutyrate: 0.8 mmol/L (mildly elevated, not ketotic)

Corrected Sodium:

• Corrected Na = 152 + 1.6 x [(1142-100)/100] = 152 + 17 = 169 mEq/L (severe!)

Effective Osmolality:

• 2(Na) + Glucose/18 = 2(152) + 1142/18 = 304 + 63 = 367 mOsm/kg

Additional Labs:

• WBC: 18.4 (likely hemoconcentration vs. infection)
• UA: Pyuria, bacteria (UTI - likely precipitant)

Diagnosis

Hyperosmolar Hyperglycemic State (HHS) with:

• Severe dehydration (estimated 10-12L deficit)
• Precipitated by urinary tract infection
• Concurrent AKI

Management - HHS Protocol

Fluid Resuscitation (AGGRESSIVE):

• Hour 1: NS 1.5L bolus
• Then: NS 500-1000 mL/hour until hemodynamically stable
• Calculate fluid deficit: Estimated 10L over 24-48 hours

Fluid Type Decision:

• Start with NS (volume resuscitation)
• After initial resuscitation: Assess corrected sodium
• If corrected Na high (>145): Switch to 0.45% NS
• When glucose <300: Add dextrose

Insulin:

• May not need initially if glucose falling with fluids
• If starting: Lower dose than DKA (0.025-0.05 units/kg/hour)
• Fluid replacement causes glucose to drop significantly
• Goal: Glucose decrease 50-70 mg/dL/hour (avoid rapid changes)

Potassium:

• Monitor closely (will fall with treatment)
• Replace when K <5.2 and UOP adequate

Osmolality Correction:

• Target decrease: 3-8 mOsm/kg/hour
• Too rapid correction risks cerebral edema

Serial Monitoring

Fluid Balance:

• Total fluids in first 24 hours: 9L
• Urine output recovered after 6 hours

Additional Management

Infection Treatment:

• Blood cultures obtained
• Started ceftriaxone for presumed UTI/urosepsis

AKI Management:

• Fluids, avoid nephrotoxins
• Creatinine peaked at 3.4, then improved

Disposition

• ICU admission
• Continuous monitoring
• Creatinine improving (1.8 at day 3)
• Transitioned to subcutaneous insulin
• Diabetes education
• Discharged day 5 to rehab
• Follow-up with endocrinology and primary care

Teaching Points

1. HHS = profound dehydration: Average fluid deficit 8-12L; aggressive replacement essential
2. Less acidosis than DKA: Enough insulin to prevent ketosis but not hyperglycemia
3. Mental status correlates with osmolality: Confusion/coma with osmolality >320
4. Fluids before insulin: Volume replacement may significantly lower glucose
5. Corrected sodium critical: Assess true sodium status; guide fluid choice
6. Mortality higher than DKA: 10-20% vs. <5%; often due to precipitating illness
7. Look for precipitant: Infection, MI, stroke common triggers
8. Slow and steady correction: Avoid rapid osmolality shifts; risk of cerebral edema

Clinical Image

Image Description: Diagram illustrating the calculation of serum osmolality and the relationship between glucose, sodium, and osmolality in hyperosmolar states such as HHS.

Attribution: Image from Wikimedia Commons, Serum osmolality. Licensed under CC BY-SA 4.0. Source: https://commons.wikimedia.org/wiki/File:Serum_osmolality_formula.svg

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