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Key concepts and immediate priorities
Hyperosmolar hyperglycemic state overview
Severe hyperglycemia with hyperosmolality and dehydration
Typical effective osmolality >320 mOsm/kg
Typical glucose >33.3 mmol/L
Minimal ketonemia compared with diabetic ketoacidosis
pH usually >7.30
Bicarbonate usually >18 mmol/L
Precipitants often drive mortality
Infection
Myocardial infarction
Stroke
Medications and missed insulin
Time critical stabilization
Airway and ventilation risk
If GCS < 13, aspiration risk escalation
If inability to protect airway, RSI pathway and ICU
Circulation and shock recognition
If SBP <90 mmHg or lactate elevated, shock pathway
If sepsis physiology, sepsis bundle and early antibiotics
Neurologic risk
Altered mental status from hyperosmolality
Focal deficits prompting stroke evaluation
Monitoring and access
Two large bore IV access
If difficult access, ultrasound guided peripheral IV or IO
Cardiac monitoring
Potassium shifts and QT concerns
Frequent vitals
At least every 15 to 30 minutes during resuscitation
Strict intake and output
Foley if severe illness or unreliable output
Bedside targets and time course
Early priorities
Restore perfusion with fluids
Correct electrolytes before insulin if needed
Osmolality safety
Gradual decline in effective osmolality
Avoid rapid sodium shifts
Glucose trajectory
Aim glucose fall 3 to 4 mmol/L per hour after insulin started
Diagnostic framing at triage
Hyperglycemic emergency sorting
HHS favored features
Marked dehydration
Marked hyperosmolality with confusion
Mild or absent acidosis
DKA overlap features
Moderate to large ketonemia
Anion gap metabolic acidosis
Mixed HHS and DKA possibility
Hyperosmolality plus high anion gap
Consultation and escalation triggers
Escalation triggers
Refractory hypotension after initial fluids
Suspected myocardial infarction, stroke, or sepsis
Severe electrolyte derangements
Potassium <3.3 mmol/L
Potassium >6.0 mmol/L with ECG changes
Severe hyperosmolality with coma
Early consultation
ICU for severe illness or neurologic impairment
Endocrinology or internal medicine for ongoing insulin strategy
Nephrology if advanced kidney failure or dialysis needs
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.