Hyperglycemic hyperosmolar state (HHS) is a diabetic emergency with very high blood glucose, often above 600 mg/dL, and severe dehydration, usually without significant ketoacidosis. It develops over days, mostly in older adults with type 2 diabetes, and is often triggered by infection or missed medicines.
Key symptoms
- Extreme thirst and frequent urination over several days
- Weakness, fatigue and weight loss
- Confusion, drowsiness or coma
- Seizures or one-sided weakness that can mimic stroke
- Symptoms of the trigger: fever, cough, painful urination
What you find on exam
- Dry mouth, poor skin turgor, sunken eyes
- Fast pulse and low blood pressure
- Level of consciousness
- Neurological exam for focal deficits
- Search for a source of infection
Tests
- Fingerstick glucose, often reading HIGH
- Electrolytes, kidney function and osmolality above 300 mOsm/kg
- Ketones and blood gas: pH usually above 7.30
- Cultures, urinalysis, chest X-ray and ECG to find the trigger
Treatment basics
- IV normal saline, often 1 liter in the first hour, then adjusted
- Insulin infusion once fluids are running and potassium is above 3.5 mEq/L
- Replace potassium as needed
- Lower glucose and sodium gradually to avoid brain swelling
- Treat the trigger and prevent blood clots
Red flags
- Coma or seizures
- Low blood pressure or shock
- Very low or very high potassium
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Related guides
Sources: NASEMSO National Model EMS Clinical Guidelines; NREMT psychomotor skill sheets (EMT and Paramedic); NCCPA PANCE Content Blueprint. Written by Making Synapses. Making Synapses is not affiliated with these organizations.