# DKA vs. HHNS



## wvditchdoc (Sep 26, 2009)

Recently had a patient found unresponsive, GCS of 3, and hypothermic (under a running AC unit, no clothes or covers). Upon arrival to the Military Hospital, his BGL was found to be over 1000. 

Official DX from the Doc was DKA, right before he got on the C-17 to LRMC. I wondered about it so did some research in the books we have available. I am unsure of the actual labs, but will try and find them tomorrow to verify a few things. 

Tried to write it out so that anyone can understand it and this is the best I can differentiate between the two:

*DKA: *The body typically does not produce insulin (Type I), therefore, other substances are utilized to produce energy because we cannot utilize sugar. This process is very "dirty" and we see the byproducts in the form of ketones. Hence, the "keto." These bodies are acidotic hence, "ketoacidosis." However, sugar continues to accumulate because it has nowhere to go. This explains the elevated blood sugars (typically in the 300 - 600 range)and acidosis seen with DKA.

*HHNS:* Hyperosmolar Hyperglycemic Nonketotic Syndrome, now this is a different animal. With HHNS, we still make insulin (Type II and Non Diabetics) and we still have sugar entering the cells. So, alternative pathways are not needed to produce energy in most cases. This process is relatively "clean" and we don't see the byproducts in the form of ketones, as we do in DKA. The profound hyperglycemia (sometimes reaching the 1000's) is a bit harder to explain. We must remember HHNS is not an exclusive diabetic condition. So, it is _often_ confusing and incorrect to compare this condition to DKA. Many cases of HHNS are precipitated by an event that dramatically alters the body's compensatory mechanisms of glucose balance. For example, people who develop pancreatitis are at risk for developing HHNS. The normal mechanisms of glucose balance are dramatically altered leading to profoundly elevated sugars. Insulin is present in these cases, and this prevents the formation of ketones.

So after knocking the dust off the books,the DKA DX seems a bit improbable. 

Any thoughts or anything to add regarding the differences? 

Thanks...


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## Shishkabob (Sep 26, 2009)

I'm fairly confident that if ketones are present (acetoacetic acid, acetone and B-hydroxybutryc acid) than it's DKA.  These ketones lower the pH of the blood from the 'normal' 7.4(+/-) to the deadly 6.9-.

The ketones are made by the body switching from glucose to fats utilizing adipose cells, which is what causes the liver to release the ketones.  Generally: insulin present = glucose used = no fat used = no ketones.  



Both are still treated pretty much the same in the field.  We're pretty much treating the hypovolemia/ dehydration caused by the osmotic diuresis from the glycouresis in both cases.


I think the only way we can get a better idea at which it is is by a good history.  DKA tends to be Type 1 DM while HHNK tends to be Type 2 DM.  And the onset is different, with DKA tending to be 12-24 hours while HHNK is days to weeks.



Yes?




A girl in my EMT class last year went in to DKA with a BGL >1000


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## Shishkabob (Sep 26, 2009)

Found this



> Symptoms: nausea/vomiting - If the patient is nauseous or vomiting, DKA is suspected. If not, HHNS is more likely.
> 
> Urine ketone tests - The presence of ketones in the urine can indicate DKA. Lack of ketones probably means HHNS.
> 
> Blood ketone tests - Blood tests to analyze ketones and acidity in the blood can help confirm DKA versus HHNS.


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## Lifeguards For Life (Sep 26, 2009)

Just reading about this i think linus summed it up pretty well. I think a good in field indicator of dka over hhns is kussmaul respirations. in dka there is not adequate insulin to get the glucose into the cells, and the glucose begins to pool in the blood stream . since the cells can not use the glucose, when all other sources are exahusted, the body starts to burn triglycerids and muscles instead of glucose. several chemical changes take place and result in the production of ketoacids namely acetoacetic acid and hydroxybutyric acid. they are both strong organic acids that result in creating a state of metabolic acidosis. The body will try to breathe off that extra c02, hince the kussmaul respirations
back to the beginning you will remember that glucose is not entering the cells and is pooling in the vessels. this results in hyperglycemia which results in fluids shifting from the interstitial space into the venous space. ketones are excreted in urine, followed by sodium and potassium. generally leading into hypokalemia.


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## Crepitus (Sep 26, 2009)

I found this link good reading.  Doesn't add alot to the excellent info already provided, but is a good short one page comparison summary.

http://medschool.ucsf.edu/sfghres/password/IS/1IS_DKA.htm


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## mycrofft (Sep 26, 2009)

*Smell the breath, sweat and urine. Like canned pears or acetone.*

They make urine dipsticks and "electrodes" (dipsticks) to test blood for ketones for some fingerstick glucometers.
Either way, IV NS, oxygen, get thee to a hospital.

I saw an unconscious DKA drawing fruitflies and ants in her garden. Lasted about another week.


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## Lifeguards For Life (Sep 26, 2009)

thanks. the patho flow chart was a little rough to look at but that link offered a good side by side comparision


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## cm4short (Sep 27, 2009)

wvditchdoc said:


> Recently had a patient found unresponsive, GCS of 3, and hypothermic (under a running AC unit, no clothes or covers). Upon arrival to the Military Hospital, his BGL was found to be over 1000.
> 
> Official DX from the Doc was DKA, right before he got on the C-17 to LRMC. I wondered about it so did some research in the books we have available. I am unsure of the actual labs, but will try and find them tomorrow to verify a few things.
> 
> Tried to write it out so that anyone can understand it and this is the best I can differentiate between the two:



Also, can you see if there was any written report on this patient's presentation along with vital signs? Kinda paint a picture so if we happen to come across this in the field we can easily differentiate. Because, if you are thinking HHNS; then you'd expect circulatory collapse opposed to kussmaul respirations.


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## Aidey (Sep 27, 2009)

I wasn't taught that any blood glucose over 1000 was automatically HHNK, but that the higher the blood glucose the more likely it was HHNK and not DKA. To truly differentiate between the two you need full labs so you know the pts acid/base balance and such. 

I had a HHNK patient with a final blood glucose of 1707. No Hx of diabetes. Pt was septic from a surgery a month previous, and it had shut down his pancreas.


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