Endo, Hemato, Renal, and Sepsis

Question 1

SIADH(Syndrome of Inappropriate ADH)

Answer 1

•Dilutional Hyponatremia
>causes cerebral edema
•Concentrated urine
•Hyponatremia symptoms may mimic CVA symptoms
•Causes:
> Carcinoma
>Head problems(trauma, tumor, CVA, Meningitis, Encephalitis)
> Hypoxemia
>Meds(anesthetics, narcotics, TCA, acetaminophen, and anticonvulsants)

Question 2

SIADH Tx

Answer 2

1) Fluid restriction
2) Hypertonic solution
3) Lasix
4) Raise Na+ 0.5mEq/L/hr (10-12mEq/24hr). any rapid increase or decrease in Na+ can cause osmotic demyelination syndrome which can lead to irreversible damage
• Remember that hypotonic solution will make SIADH worse.

Question 3

Diabetes Insipidus

Answer 3

•Opposite of SIADH- low levels of ADH
•Can have large loss of water.
•Lab findings: Increased Na+ and serum osmolality. Low specific gravity
•Causes: Head injury, Infection, Tumor, drugs. ——> leads to: hypovolemia, shock, and electrolyte imbalance.

Question 4

Diabetes Insipidus symptoms and treatment

Answer 4

•Symptoms: #1-Dehydration—dry mucus membranes, Tachycardia, Sunken fontanelles, excessive thirst. #2-Electrolyte imbalance—Fatigue/Lethargy, HA, Irritability, muscle pain.

•Tx:
•Aggressive IVF replacement
•Vasopressin (synthetic ADH)
•Desmopressin(DDAVP)
•Monitor specific gravity
•Monitor cardiac changes

Question 5

DKA

Answer 5

— characterized by hyperglycemia, dehydration, and acidosis. Typically type 1 diabetics
• Common causes: infection, non-compliance with insulin, or new onset diabetes.
•Symptoms: state of acidosis, ketone breath, Kussmaul resp, K+ loss, dilutional Hyponatremia, ALOC.

Question 6

How to find correct Na+

Answer 6

Measured Na +(serum glucose-100)0.016

*for q 100mg/dL of glucose over 100, Na+ drops by 1.6mEq/L

Question 7

HHNK Tx
(hyperosmotic hyperglycemic nonketotic) state

Answer 7

•Fluid replacement
•Insulin administration
•K+ replacement
•Usually don’t have acidosis and have higher BGLs and usually type 2 diabetics
•check BGL

Question 8

Hypervolemic Hyponatremia

Answer 8

—more water than Na+
•Kidneys are not able to excrete water efficiently. Seen in volume overload patients like: CHF, cirrhosis, and kidney injury. Edema usually present
•Common Tx: Na+, fluid restriction, and diuretic therapy.

Question 9

Euvolemic Hyponatremia

Answer 9

—fluid overload with normal Na+
•Caused by SIADH. Normal BUN and Cr ratio. Urine specific gravity will be high(concentrated urine) due to overstimulation of ADH.
•Tx: if SIADH= fluid restriction. Hypertonic NS with slow increase in serum Na+ and Lasix can be given.

Question 10

Thyroid storm

Answer 10

— high amount of free Thyroxin(T4) and Triiodothyronine(T3), with depressed amount of thyroid-stimulating hormone(TSH)
*can be precipitated by many different factors
*may present very similar to excited delirium.
*Symptoms: N/V/D, tachy arrhythmias(a-fib), hyperthermia, confusion, and severe delirium.

Question 11

Thyroid storm Tx

Answer 11

Tx goals:
• block the formation of new hormones in the thyroid gland
• Inhibit the action of hormones that are formed
• Support vital functions
• Identifying treat the precipitating event
>Meds for Tx
• Glucocorticoid
•Acetaminophen
• Ice packs for active cooling
• Beta blockers(Propranolol or Esmolol.
•Propylthiouracil(PTU) or methimazole
* PTU can deplete platelet count
** never delayed treatment while waiting for labs. If untreated, mortalities is nearly 100%.
***Don’t give ASA

Question 12

Myxedema Coma

Answer 12

—(Opposite of Thyroid Storm)
• extreme manifestation of hypothyroidism
• physical findings: AMS, Alopecia, hypotension, bradycardia, delayed reflex relaxation, dry/cool/doughy skin, hypothermia, Myxedematous face
•Free T4 and T3 decreased and TSH elevated.
—Tx:
•IV thyroid hormone replacement
•IVF resuscitation
•Vasopressors
•IV corticosteroids

Question 13

Cushing Syndrome

Answer 13

—caused by prolonged exposure to glucocorticoids or pituitary tumor
•Physical findings: weight gain(buffalo hump), skin changes(stretch marks, bruise easily), Hirsutism, Menstrual irregularities/amenorrhea, impotence, and osteopenia.

Question 14

Adrenal Insufficiency

Answer 14

—Lack of cortisol; body cannot maintain essential life functions
•Physical Findings: Fatigue/weakness, dizziness when standing, loss of appetite, and joint aches and pains.
Tx: Glucocorticoids(hydrocortisone, dexamethasone, prednisone)
*can see HTN and hyperglycemia as refractory issue

Question 15

Sickle Cell Crisis

Answer 15

•Autosomal recessive
•most exclusive to African American and African ancestry
•Abnormal RBC
•Increased risk of infection
—Symptoms: severe pain. Many different triggers(infection, stress, hypoxia, temp changes)
—Tx: pain control, IVF, treat infection, PRBCS possibly

Question 16

DIC

Answer 16

—Disseminated Intravascular Coagulopathy
•Overstimulation of clotting cascade secondary to massage tissue damage
Tx: Heparin, Antithrombin 3. TXA(only if actively bleeding.

Question 17

Clotting cascade

Answer 17

•Step 1- vascular spasms post injury
•Step 2- platelet plug formation
•Step 3- coagulation

Question 18

Sepsis

Answer 18

–Life threatening organ dysfunction caused by dysregulated host response to infection
- Infection that has been overwhelmed. Massive vasodilation and capillary leakage.
Sepsis Tx:
-Fluid resuscitation(30mL/kg initially)/be careful to not fluid overload, may lead to ARDS type patient. Follow protocols.
-Vasopressors(target MAP of 65 or >. Levophed primary, Vasopressin secondary if they can handle it.
-Consider Dobutamine

Question 19

qSOFA (Sepsis criteria)

Answer 19

–Sequential Organ Failure Assessment (Sepsis criteria)
> Need 2 or more of the following criteria to be considered Sepsis positive:
-RR > 22/min
- Altered mentaion(anything <15)
- SBP 100mmHg or less
> Some systems use ETCO2 <25 in addition or initial lactate >4

Question 21

Quiz question
Which lab finding would be most associated with diabetes Insipidus

Answer 21

Answer: Urinary hypo-osmolality

Explanation: diabetes insipidus occurs from low level of ADH, so the patient loses large amounts of water, which decreases urinary concentration.