Clinical Commander

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endo.hhs.core.v1

Hyperosmolar hyperglycemic state (adult)

endocrinologyacuteadultacuteinpatient
Start encounter →Print handoutPRODUCTION

protocol.dka in registry covers mixed DKA-HHS branch but no dedicated HHS protocol id exists yet — fluid-first JBDS algorithm runs through cascade.fluid + insulin-dosing service. No atoms.assessment / atoms.treatment files on disk — only single atoms.ts. 2026-05-13 deepening pass — added 4 severity_triggers (free_water_deficit_severe, beers_list_precipitant_active, hypernatremia_post_correction) and a 4-stage transitions block (admit/escalation/de-escalation/discharge) with explicit handoff payloads. 2026-05-22 citation remediation — removed 4 off-topic placeholder PMIDs (HF editorial, ProCESS sepsis, POINT stroke, biomass-fuel anaemia) and replaced with live-verified anchors: 39052901 (2024 ADA/EASD/JBDS/AACE/DTS Hyperglycemic Crises Consensus, covers HHS) and 19564476 (Kitabchi 2009).

Entry points (4)

  • lab_abnormality
    Glucose ≥600 mg/dL (ADA 2026 §16; Kitabchi 2009)
    severe_hyperglycemia
  • symptom
    AMS in elderly diabetic (JBDS-IP 2023; Scott 2015 UK audit)
    altered_mental_status
  • lab_abnormality
    Effective osmolality >300 mOsm/kg without ketoacidosis (ADA/EASD 2024 consensus)
    hyperosmolality
  • problem_list
    Known T2DM + dehydration / infection trigger (Pasquel 2014; JBDS-IP 2023)
    type_2_diabetes_dehydration

Required inputs (11)

  • agerequired
    demographic • used at CONTEXT
    Elderly substrate; silent precipitants (MI/sepsis); drug list per Beers 2023 (Scott 2015 UK audit)
  • weightrequired
    demographic • used at TREATMENT
    Fluid + insulin dosing weight-based; total deficit often 6–9 L (JBDS-IP 2023; Kitabchi 2009)
  • glucoserequired
    lab • used at INITIAL_WORKUP
    ≥600 mg/dL diagnostic threshold (ADA 2026 §16); switch to dextrose-containing IVF when <300 (JBDS-IP 2023)
  • osmolalityrequired
    lab • used at INITIAL_WORKUP
    Effective osmolality >300 mOsm/kg defines HHS (ADA/EASD 2024 consensus)
  • bhbrequired
    lab • used at INITIAL_WORKUP
    BHB <3.0 distinguishes from DKA; ≥3.0 → mixed DKA-HHS (ADA/EASD 2024 consensus)
  • phrequired
    lab • used at INITIAL_WORKUP
    pH >7.30 in pure HHS; lower → mixed DKA-HHS (ADA/EASD 2024 consensus; Kitabchi 2009)
  • sodiumrequired
    lab • used at INITIAL_WORKUP
    Corrected Na trend drives ½NS switch; ODS-prevention rate ceiling (JBDS-IP 2023; Adrogué-Madias NEJM 2000)
  • potassiumrequired
    lab • used at INITIAL_WORKUP
    Total-body K depleted but serum may be normal/high; replete before insulin (ADA 2026 §16; Kitabchi 2009)
  • creatininerequired
    lab • used at INITIAL_WORKUP
    Pre-renal AKI universal in HHS; gates dosing (Pasquel 2014; KDIGO 2024)
  • precipitant_screenrequired
    history • used at CONTEXT
    Infection #1 (UTI/pneumonia/sepsis), MI/stroke, drug (steroid/SGA/thiazide) (JBDS-IP 2023; Pasquel 2014)
  • current_meds
    medication • used at CONTEXT
    Beers 2023: thiazides, steroids, SGAs, phenytoin, beta-blockers precipitate HHS (JBDS-IP 2023; Scott 2015)

12-phase flow (12)

  1. 1FRAME
    Confirm HHS criteria (glucose ≥600, eff osm >300, pH >7.30, BHB <3.0, AMS) and exclude pure DKA / mixed DKA-HHS (ADA/EASD 2024 consensus; ADA 2026 §16)
    inputs: glucose, osmolality, ph, bhb
    advance: HHS criteria met per ADA/EASD 2024 consensus
  2. 2ENTRY
    Capture trigger (severe hyperglycemia, AMS, hyperosmolality) per ADA/EASD 2024 consensus
    inputs: age, weight
    advance: demographic captured
  3. 3CONTEXT
    Capture diabetes type/duration, recent water intake, infection screen, MI/stroke screen, medication list (Beers 2023 triggers) (JBDS-IP 2023; Pasquel 2014)
    inputs: precipitant_screen, current_meds
    advance: precipitant identified or screen in flight
  4. 4RED_FLAGS
    Coma/seizure, refractory shock, K abnormalities, severe hypernatremia, MI/stroke as silent precipitant, sepsis (JBDS-IP 2023; Kitabchi 2009; Scott 2015)
    inputs: glucose, sodium, potassium
    actions: calc.qsofa
    advance: red flags screened; ICU triggered per JBDS-IP 2023 criteria
  5. 5INITIAL_WORKUP
    BMP, ABG/VBG, BHB, AG, measured + effective osmolality, corrected Na, lactate, CBC, Mg/Phos, A1c, ECG, troponin if cardiac risk, CXR, urine + blood cultures, CT brain if focal AMS (ADA 2026 §16; JBDS-IP 2023; Kitabchi 2009)
    inputs: glucose, osmolality, bhb, sodium, potassium, creatinine
    actions: panel.glucose_a1c, panel.abg, panel.renal, workup.dka_hhs
    advance: osmolality + Na + K + precipitant labs returned
  6. 6BRANCHING_WORKUP
    Mixed DKA-HHS subprotocol if BHB ≥3 + acidosis (ADA/EASD 2024 consensus); precipitant-specific (sepsis bundle SSC 2026, NSTEMI workup, stroke imaging)
    advance: phenotype-specific workup queued
  7. 7DIFFERENTIAL
    Exclude pure DKA, mixed DKA-HHS, hyperglycemia-induced AMS without HHS, primary stroke/CNS process (ADA/EASD 2024 consensus; Kitabchi 2009)
    advance: differential narrowed
  8. 8RISK_STRATIFICATION
    NEWS2 + qSOFA (Sepsis-3 2016) for sepsis precipitant; severity per osmolality + AMS depth; mortality 5–20% (Scott 2015 UK audit; Pasquel 2014)
    actions: calc.qsofa, calc.sofa
    advance: severity + ICU disposition assigned per JBDS-IP 2023 criteria
  9. 9TREATMENT
    JBDS-IP 2023 fluid-first: 0.9% NaCl 1 L/h × 1h then individualize; delay insulin until glucose stops falling with fluids alone OR BHB >1 (JBDS-IP 2023); insulin 0.05 U/kg/h fixed-rate when started; switch to D5 ½NS at glucose ~300; aim glucose fall <90 mg/dL/h, osmolality fall <3–8 mOsm/kg/h; VTE prophylaxis mandatory (JBDS-IP 2023); treat precipitant
    inputs: weight, glucose, sodium, osmolality
    actions: protocol.dka
    advance: fluids running; insulin started per JBDS-IP 2023 criteria; precipitant therapy in flight
  10. 10DISPOSITION
    ICU mandatory if shock, AMS, mixed DKA-HHS (JBDS-IP 2023); step-down once glucose <300 + osm <320 + alert (ADA 2026 §16)
    advance: level of care assigned per JBDS-IP 2023
  11. 11MONITORING
    Hourly glucose, BMP q1–2h, corrected Na q1–2h, osmolality q2–4h, neuro checks q1h, strict I/Os, telemetry, daily VTE-prophylaxis review (JBDS-IP 2023; ADA 2026 §16)
    inputs: glucose, sodium, osmolality, potassium
    actions: panel.renal, panel.glucose_a1c
    advance: resolution criteria met (osm <315, alert, eating) per JBDS-IP 2023
  12. 12FOLLOWUP
    Endo + diabetes education; review precipitant; revise outpatient T2DM regimen per ADA 2026 §9 cardiorenal-first (SGLT2i/GLP-1 RA); medication reconciliation removing precipitating drugs (Beers 2023)
    advance: follow-up scheduled; outpatient regimen optimized per ADA 2026