ENDOCRINE Flashcards
addison crises
life threatening emergency due to acute adrenal insufficiency (decrease in MC - aldosterone and GC -corticosteroids
addison crises RF predisposing
existing adrenal disease (primary adrenal disease , adrenalitis) female long term steroid infiltration (TB, sarcoid, mets) Heparin and Warfarin Coeliac (11X increase)
addison crises RF precipitates
Abrupt withdrawal of exogenous steroids Pituitary infarct Surgical cure of Cushing’s syndrome Concomitant infection/illness Adrenal haemorrhage
signs addison crises
Volume depletion/Shock Hypotension Particularly postural Coma Febrile/fever Hyper-pigmentation If long standing adrenal insufficiency
symptoms of addison crises
Confusion Collapse/Faints Particularly when stand up Acute abdomen Anorexia, nausea, vomiting, diarrhoea, weight loss & pain Anorexia Fatigue Psychiatric features Myalgia, arthralgia, muscle cramps (high K)
NA, K , urea, Calcium , glucose, volume findings of addison crises
Hyponatraemia Hyperkalaemia Elevated Urea: (volume depletion secondary to Urinary Na loss) Hypercalcaemia hypoglucose NOT: HYPOvelemia
ACTH levels in addison crises
if primary (Autoimmune, TB , nets or Waterhourse friderichsen syndrome) - HIGH
Secondly cause - decrease ACTH
why fluid do u give in addison crises
- CALL for help
- IV fluids - crystalloid - NaCl 0.9%
Avoid hypotonic saline… worsens hyponatraemia
Can substituted Dextrose 5% if hypoglycaemic, but beware inducing seizures secondary to worsening hyponatraemia
ACUTE treatment for addison crises
- Call for help
- IV fluids - NaCl 0.9%
- Urinary Cauterization
- IV hydrocortisone - 100mg-200mg stat (Every 4-6 hour)
alternating with Dexamethasone 4mg, IV OD x 3/7
LONG TERM treatment addison crises
Oral dosing, two drugs usually Glucocorticoid: e.g. Hydrocortisone Often morning (+/- lunchtime, evening) e.g. hydrocortisone PO 15mg mane, 5mg at lunch, 5mg tarde
Mineralocorticoid:
e.g. fludrocortisone Acetate 0.1mg OD
Wear a bracelet/alert
Don’t forget bone protection, prophylaxis against gastritis
Yearly HBA1c, U&E, lipid profile, BP checks
Sick day rule for steroids addison crises
Double dose of steroid for sick days
DKA definition
A hyperglycaemic crisis, with…Dehydration AND ketones
A life threatening complication
Hyperglycaemic state (not as high as HHS, i.e. > 11.1mmol/L)
significant fluid deficit: (often 5-8L) (less than HHS)
Importantly: positive ketones in urine or serum
Acidotic: pH < 7.3, Bicarbonate < 18mmol/L
RF for DKA
Predisposing
- T1DM
- YOUNG
- OFTEN - never dx, female (skipping meals) , poor nutrition
Precipitating
- sepsis
inadequate insulina ttreatment
iatrogenic drug ( steroids, cociane )
signs DKA
Tachypnoea: Ketotic breath Kussmauls breathing Neurological signs: Reduced GCS Confusion... Coma Seizures Volume depletion: Decreased skin turgor Dry mucous membranes Tachycardia Low JVP Hypotension/particularly postural Oliguria Succussion splash, absent bowel sounds
symptoms
SKA
Glycosuria Polyuria Polydipsia Weight loss Lethargy Nausea Vomiting (secondary gastroparesis) Abdominal Pain: Muscle cramps
osmolarity in DKA
Hyperosmolality/hyperglycaemia/acidosis
with increase anion gap
ecg in DKA
Rate… How tachycardic
Rhythm… Any arrhythmia present
Strain or ischaemia… Any TWI, ST changes
Any evidence of MI as trigger for DKA or complication from AKI or electrolyte imbalance
gnereal DKA treatment
Fluid replacement
- 0.9% saline per kg in 12-20ml.kg/h OR 1L state , 1L over 2 hours, 1L over 2-4 hours 1L 2-6h, 1L over 8h
Insulin
Act rapid - 5-10U (saintaince 50U diffused into 50mls of 0.9% saline
Aim to decrease glucose by 5mmol/h
Potassium monitoring & replacement (In that order!!) - at least 50mls/h
Prophylactic SC heparin or LMWH
IV antibiotics if warranted
Acidosis correction
Potassium monitoring & replacement
<3.3mmol/L - add 40 mEqKCL to 1 L of infusing IV
3.3-5.3 - add 20meQ to iL of infusing IV fluid
> 5.3 - stable - observe and respect K levels in 2 hours , stop any K infusions
Unstable : - cardioprotect for hyperkalemia and then consider dialysis
what happens to Na , K , phosphate ,mg and ca in DKA
DECREASE
when do you switch a DKA patient from IV to subcutaneous insulin
- patient must have free ketones for 24 hours, eating and drinking before you switch
Complications of DKA
- cerebral edema and osmotic demyelination (if Na is correct too fast)
- aspiration pneumonitis
- sepsis
- ACS
treatment of cerebral edema and osmotic demyelination complication in DKA
Mannitol and may need IV dexamethasone
HHS definition
hyperglycaemic > 30 mmol/l
- fluid losses: 100 -220 ml/kg
- no ketones
(in many ways more sinister as patient is often older with more co-morbidities and onset is insidious)
osmolarity > 320 mosmol
RISK HHS
Predisposing
Type 2 diabetes
(some residual insulin secretion is usually present: thus reducing the risk of DKA)
> 65 years of age
Often: patient never previously diagnosed with diabetes
Precipitant Sepsis MI/stroke Elevated stress hormones (cortisol/glucagon) Inadequate insulin therapy Decreased water intake Iatrogenic: Steroids, thiazide diuretics
osmolarity in HHS
osmolarity > 320 mosmol
ph in hHS
non acidic therefore NORMAL
ABGs in DKA
low Ph
high bicarb
incase pCO2
Treatment HHS
Fluid replacement
0.9% Nacl (15-20ml stat) or IL over… etc
Insulin
Act rapid 0.1u/kg as boules (if K > 3.5)
Potassium monitoring & replacement (In that order!!)
Early senior/specialist review.
Prophylactic LMWH
IV antibiotics if warranted
aim to lower glucose when treating HHS
decrease glucose at a rate of ~3 mmols/hour
Double dose of IV insulin infusion if not reaching target.
(IV dose 0.1u/kg)
when do you add glucose to fluid when correcting HHS
add glucose to fluid when the blood glucose DROPS to 14
when do you adjust insulin requirements when treating HHS
When reaches 13.9 to 16.7 mmol/L
IV insulin can be tapered and SC insulin started.
HHS target blood glucose
Target blood glucose (JBDS): 10-15 mmol/L in the first 24 hours.
potassium replacement in HHS
<3.3mmol/L - add 20- 40 mmil KCl o 1 L of infusing IV
3.3-5.3 - add 20 -30 mmol to iL of infusing IV fluid
> 5.3 - stable - observe and respect K levels in 2 hours , stop any K infusions
Unstable : - cardioprotect for hyperkalemia and then consider dialysis
complications of HHS
Seizures, cerebral oedema and central pontine myelinolysis
DVT, MI, stroke
myxoedema coma
life threatening complication of underlying thyroid disease
MORTALITY : 30-40%
HYPOTHROUDIS STATE + CLINICAL MANIFESTATION * comatose, hypothermic , organ failure
ABG myxoedema coma
Resp failure
myxoedema coma treatment
IV fluids: Use Saline (0.9%
Be cautiou over-load easily (b/c hypotensive)
Warming
Broad spectrum antibiotics ( if infection suspected)
Correct any glucose abnormality:
Hypoglycaemia is likely
T3 (instead of T4 (initially)) IV
i.e. tri-iodothyronine, liothryronine
Given Intravenously
Dose 5-20mcg… Give slowly! - to prevent arrhythmia
IV hydrocortisone
E.g. 100mg QID
Partially as a “stress dose”
Also until coexisting adrenal insufficiency is excluded
A 67 year old woman is reviewed in the emergency department with stupor and decreased consciousness. what clinical feature is more suggestive of a diagnosis of Myxoedema Coma rather than Addisonian crisis.
Temperature of 35.4 degrees centigrade
definition for endocrine thyrotoxic storm
life threatening complication of underlying thyroid disease HYPERTHYROID STATE + clinical manifestation - fever - jaundice - abdo pain - N V D Signs: - febril - confusion - tachycardia w/ arrhythmia Multisystem decompensation
RF for thyroidtoxic storm precipitating
Sepsis Withdrawal of anti-thyroid medication(s) Iatrogenic/OD (eltroxin) Metabolic abnormalities DKA, etc Recent surgery Thyroid Non-thyroid Radio-iodine therapy Iodinated contrast dye
thyroid toxic storm organ involvement
Multi-system decompensation: Cardiac failure Respiratory distress Congestive hepatomegaly Dehydration Pre-renal failure
what do you see on FBC with thyroidtoxic storm
normacystic anemia
mild neutropenia
leucocytosis
thrombocytopenia
treatment of thyroidtoxic storm
IV fluids:
Antipyretic
Paracetamol AND Chlorpromazine… For hyperpyrexia and agitation
Broad spectrum antibiotics: (empiric) - if infection suspected
Propanolol - 60-80mg every 4-6 hours (2-5mg/jour IV infusion)
Antiarrythmic - DIGOXIN (if in a.fib give anticoagulant first)
propthriouracil -200-300QDS
Potassium iodide - PO/NG 1-6 hours after propthriouracil
60mg Prednisone PO/ NG OD OR 100mg Hydrocortison
resistant treatment of thyroidtoxic storm
- plasmapheresis
- peritoneal dialysis
- cholestyramine
what makes thyroidtoxic storm worse
ASA - b/c it displaces T3 and T4 to their protein binding site
