DKA and HHS- Fluids, yes please

A 47 year old male presents after returning from a trip to Orlando. He was visiting Harry Potter World and states he had left his insulin at home and instead prescribed himself Butterbeers BID. He rode “Escape from Gringotts”, but shortly after his third ride his friend noticed his skin and facial complexion looked much worse than one of the goblins. An ambulance was called. En route the patient’s friend tweeted #HogwartsExpresss. The patient arrived tachycardic with poor capillary refill. He was lethargic and unable to provide any history and was disoriented.

Which of the following is true regarding this patient’s condition?

A. DKA has a higher mortality than HHS

B. Thromboembolic events are the most common cause of death in HHS

C. Cerebral edema is managed with prompt diuretics and steroids

D. Mental status changes are correlated with changes in serum osmolarity in HHS

References:

American Diabetes Association: Hyperglycemic crises in patients with diabetes mellitus (Position Statement). Diabetes Care 24:1988–1996, 2001

Driver BE et al. Discharge glucose is not associated with short-term adverse outcomes in emergency department patients with moderate to severe hyperglycemia. Ann Emerg Med 2016 Dec; 68:697.

Basu A, Close CF, Jenkins D, Krentz AJ, Nattrass M, Wright AD: Persisting mortality in diabetic ketoacidosis. Diabet Med 10:282–289, 1992

Bello FA, Sotos JF: Cerebral oedema in diabetic ketoacidosis in children.Lancet 336:64, 1990

Boyd JC et al. Relationship of potassium and magnesium concentrations in serum to cardiac arrhythmias. Clin Chem 1984; 30(5): 754-7. PMID: 6713638

Ennis ED, Stahl EJVB, Kreisburg RA: The hyperosmolar hyperglycemic syndrome. Diabetes Rev 2:115–126, 1994

Gerich JE, Martin MM, Recant LL: Clinical and metabolic characteristics of hyperosmolar nonketotic coma. Diabetes 20:228–238, 1971

Guisado R, Arieff AI: Neurologic manifestations of diabetic comas: correlation with biochemical alterations in the brain. Metabolism 24:665–669,1975

Kaufman FR, Halvorson M: The treatment and prevention of diabetic ketoacidosis in children and adolescents with type 1 diabetes mellitus. Pediatr Ann 28:576–582, 1999

Kitabchi AE, Ayyagari V, Guerra SMO, Medical House Staff: The efficacy of low dose versus conventional therapy of insulin for treatment of diabetic ketoacidosis.Ann Int Med 84:633–638, 1976

Kitabchi AE, Umpierrez GE, Murphy MB, Barrett EJ, Kreisberg RA, Malone JI, Wall BM: Management of hyperglycemic crises in patients with diabetes. Diabetes Care 24:31–53, 2001

Morris LR, Kitabchi AE: Efficacy of low-dose insulin therapy for severely obtunded patients in diabetic ketoacidosis. Diabetes Care 3:53–56, 1980


Blake Briggs