HSS

Question 1

Airway

Answer 1

usual

Question 2

Breathing

Answer 2

Look
Listen
Feel

RR, O2

ABG: ketones, acidosis, glucose
CXR?

Question 3

Circulation

Answer 3

Look
Listen
Feel

HR, BP

• Bloods: FBC, UEs, LFTs, CRP, VBG, capillary glucose
• Get IV access

Management:
* IV fluids 0.9% saline over 48 hours, Na fall should not exceed 0.5 mmol/h
* Insulin: only used if significant ketonaemia (>1mmol/L) or plasma glucose not falling with IV fluids
* Consider thromboprophylaxis (treatment dose)

Escalate:
* Seek senior support
* ITU/ HDU support
* Inform diabetes/ endocrinology team

Question 4

D&E

Answer 4

BM, PEARL, GCS, insulin chart, abdo exam, temp, calves

Question 5

What is HHS

Answer 5

Hyperglycaemic hyperosmolar state (HHS)

1. Hypovolaemia +
2. Hyperglycaemia (>30mmol/L) without significant ketonaemia (<3 mmol/L) or acidosis (pH >7.3)
3. Osmolality >320 mosmol/kg 2(Na+K) + urea + glucose

Info:
* Seen in unwell patients with T2DM
* Hx is longer e.g. 1 week with marked dehydration and glucose >30 mmol/L
* >320 mosmol/kg
* Occlusive events are danger – focal CNS signs, chorea, DIC, ischaemia, rhabdomyolysis
* Rehydrate slowly with 0.9% saline IV over 48 hours – around 8-15L for a 70kg adult
* Replace K+ when urine starts to flow
* Only use insulin if blood glucose not falling by 5mmol/L/h with rehydration or if ketonaemia – start slowly with 0.05U/kg/h
* Keep blood glucose at least 10-15mmol/L for first 24 hours to avoid cerebral oedema
* Look for cause e.g. MI, drugs, sepsis or bowel infarct
* Lactic acidosis – serious complication of DM with metformin use or septicaemia. Blood lactate>5. Seek expert help. Treat sepsis, maintain BP, stop metformin
* May get hypernatraemia in HHS!