Welcome to the Emergency Medicine Cases Podcast.

I'm your host, Dr. Anton Hellman, bringing you Canada's brightest minds in emergency medicine from EMC Studios in Toronto.

All right, welcome back Dr. Summer, Dr. Tillman, and Dr. Bamel, to this part two of our series on DKA and HHS.

This part two is dedicated to HHS. So let's just jump straight into a case.

A 77-year-old man arrives with his wife via EMS.

He appears lethargic.

His wife says that over the past eight days, he's become increasingly weak, stopped walking, and this morning would not talk to her.

His vital signs are normal, except for a blood pressure of 90 on 62 and a pulse of 115 beats per minute.

A cap glucose reads high and his venous pH is 7.37. Not too bad.

We talked about how D.K.A. can mimic or be triggered by an acute abdomen in part one of this series on DKKHHS.

Similarly, HHS can be triggered by or confused with a primary neurologic problem.

So Dr. Bamel, how do we sort this out?

Yeah, so I would start with a healthy amount of respect for the elderly patient that is

hyperglycemic and altered.

The in-hospital mortality in Ontario is reported as 16% for patients like this one.

And again, it's hard to know from the outset, is it all metabolic or is there

something else that's contributing to his unwellness? For example, an acute neurological event,

like a stroke or sepsis. So in this patient, I would keep my work up quite broad. I would start

with serum ketones or urinary ketones and serum

osmoles to see if there's coexisting DCA, 20 to 30 percent of these patients can also have DCA.

I would send for urine and blood cultures as well as a chest x-ray to look for signs of an occult

infection, and I would have a low threshold for starting

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