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Houseman (break your leg) > Endocrine > Flashcards

Endocrine Flashcards

1
Q

DKA

A

Admission

  • DM diet; NPO (sig GI upset/ low GC)
  • Neuro-obs q1H, obs q4H
  • Strict IO
  • H’stix q1H
  • Foley to BSB, UO q1H
  • Bld x CBC LFT Bone clotting RG ketone VBG serum osm HbA1c, BAHA (TFT, CRP, Mg anion gap lactate)
  • Septic workup: CXR, MSU x RM C/S, bld C/S, NPA, diagnostic paractentesis
  • Resume usual meds
  • IV insulin infusion + Hstix q1H
  • IVF: NS 500mL + 10-20mmol KCl q6H-q8H
    &raquo_space;» hypernatremia >150: 0.45 NS
    &raquo_space;» glc <14: 1/2:1/2 or D5
    &raquo_space;» Aim Na decrease 10-12mmol per day
  • Insulin pump (sliding scale): 49.5ml + 0.5U actrapid HM (1U in 1mL)
  • Rate: 0.1U/kg/H; aim glc drop 3-4mmol per H; 0.05-0.1U/kg/H when glc <14
    &raquo_space;» 4.2-6.7: 0.5U actrapid HM
    &raquo_space;» 6.7-8.9: 1U actrapid HM
    &raquo_space;» 8.9-11.1: 2U actrapid HM
    &raquo_space;» 11.1-16.7: 3U actrapid HM
    &raquo_space;» 16.7-27.8: 4U actrapid HM
    &raquo_space;» 27.8: 6U actrapid HM + inform
  • Acidosis pH6.9-7.0: NaHCO3 8.4% 50mL q30min x1
  • ICU consult prn

Ix
DKA: BG >11, pH <7.3, bicarb <15, urine ketone +, Bld BOHB >=3, drowsy/stupor/coma
HHS: BG >33.3, pH >7.3, bicarb >18, urine ketone -/ low +, serum som >320, stupor/ coma/ dehydration

Mx

  • NPO (significant GI upset, decresed GC)
  • Foley to BSB, strict IO
  • Obs q4H
  • Bld x CBP, LRFT, clotting, bone, RG ketone VBG serum osm, HbA1c (TFT, CRP)
  • Septic workup: CXR, MSU x RM C/S, bld C/S, NPA, diagnostic paractentesis

Ward complain

  • correct e disturbance
    1. hyperK (cardiac monitoring + IV Ca gluconate, NOT DI drip, NOT NaHCO3)
    2. hypoK (w/h IV insulin if hypoK / 40mmol/L of infusion if K 3.5-5.5); ALWAYS RFT q4H
  • correct hydration
    1. DKA fluid deficit: 100mL/kg
    2. HHS fluid deficit: 100-220ml/kg
    3. initial fluid: 0.9%NS 1L over 1H; relpace 50% estimated deficit in first 12H and the remained in the following 12H
  • insulin
    1. IV insulin infusion: actrapid 20U in 100mL NS (0.1U/kg/H), H’stix q1H
    2. Increase infusion by 1U/H cannot meet target of: dec glc 3-4mmol/L/H, inc HCO3 3mmol/L/H, dec ketone 0.5mmol/L/H, K 4.5-5.5mmol/L
  • precipitating factor
    1. Empirical abx
  • close monitoring in ICU

Monitor resolution
pH .7.3, Bld ketone <0.6

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2
Q

H’stix H

A

Ward complain
- too high consider DKA/ HONK

Check body temap, hydration, gcs
Prelim biochem from AED

Hx
Hyperglycemic symptoms: polyuria, polydipsia, polyphagia
Systemic review: abd pain, vomiting
Precipitating factor/ secondary causes of DM (IVF/ med/ TPN/ RT/ withheld DM meds/ infection/ pain/ peri-op/ ACS)
Trace and document Hba1c + document antiDM drugs (patient hx taking)

PE
vitals
Chest, CVS, Abd, Calves, NEURO

Ix
DKA: BG >11, pH <7.3, bicarb <15, urine ketone +, Bld BOHB >=3, drowsy/stupor/coma
HHS: BG >33.3, pH >7.3, bicarb >18, urine ketone -/ low +, serum som >320, stupor/ coma/ dehydraiton

Mx
- if DAT, resume DM meds
- if NPO, DKI drip with SC actrapid sliding scale q4H
- Obs q4H
- Bld x CBP, LRFT, clotting, bone, RG ketone VBG serum osm, HbA1c (TFT, CRP)
- Septic workup: CXR, MSU x RM C/S, bld C/S, NPA, diagnostic paractentesis
- AXR + amylase if vomiting
- SC Actrapid HM stat (NOT for nocte/ non-premeal)
&raquo_space;» 14-18: 4U
&raquo_space;» 18-22: 6U
&raquo_space;» >22: 8U
- After dinner, 4-6U if >22

 - Insulin sliding scale TDS premeal
 >>>> <13: 0U
 >>>> 13-15: 4U
 >>>> 15-20: 6U
 >>>> 20-25: 8U
 >>>> >25: inform
  • Resume usual meds with caution
    &raquo_space;» NOT metformin if renal impaurnent
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3
Q

HONK

A

Admission

  • DM diet
  • Neuro-obs q1H
  • Chart IO
  • Hstix q1H
  • Foley to BSB, UO q1H
  • Consider CVP
  • Bld x CBC LFT bone clotting Mg anion gap lactate RG BAHA
  • Bld x RFT, VBG, osm q6H
  • Bld C/S if fever >38
  • Urine x stix, C/S
  • Sputum x C/S
  • CXR
  • Urgent CTB (HONK)
  • Resume usual meds
  • Insulin pump: 49.5mL + 0.5U actramid HM (1U in 1mL)
  • Rate: 0.15U/kg IV bolus, aim decrease glc 3-4mmol per H; 0.05-0.1U/kg/H if glc <14
    &raquo_space;» 4.2-6.7: 0.25U actrapid HM
    &raquo_space;» 6.7-8.9: 0.5U actrapid HM
    &raquo_space;» 8.9-11.1: 1U actrapid HM
    &raquo_space;» 11.1-16.7: 1.5U actrapid HM
    &raquo_space;» 16.7-27.8: 2U actrapid HM
    &raquo_space;» >27.7: 3U actrapid HM + inform
  • Acidosis pH 6.9-7.0: NaHCO3 8.4% 50mL q30min x1
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4
Q

Hyponatremia/ addisonian crisis

A

Admission

  • DAT
  • Obs q4H
  • Neuro obs q4H if seizure
  • Seizure chart
  • Bld x TSH spot cortisol serum osm
  • Bld x CBC LRFT clotting
  • Bld x C/ST
  • CXR
  • Urine x stix C/ST
  • Urine x osm, sodium
  • U CTB if <115
  • IVF: NS 500mL q5-8H
  • 1/2 1/2 500ml q6-8H
  • IV hydrocortisone 100mg q6-8H
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5
Q

Insulin pump

A

D

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6
Q

Hyponatremia/ addisonian crisis

A

Admission

  • DAT
  • Obs q4H
  • Neuroobs q4H if seizure
  • Seizure chart
  • Bld x CBC LRFT bone clotting TSH, spot cortisol, serum osm
  • Bld C/S
  • CXR
  • Urine x stix, C/S, osm, sodium
  • Urgent CTB if Na <115
  • IV NS 500mL q5-8H / IV 1/2 1/2 q6-8H
  • IV hydrocortisone 100mg q6-8H if Na <115
  • Consult ICU if Na <115
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7
Q

Insulin pump

A 
Ward complain
For DKA
 - Insulin pump: 49.5mL + 0.5U actrapid HK (1U in 1mL)
 >>>> 4.2-6.7: 0.5U actrapid HM (U/H)
 >>>> 6.7-8.9: 1U actrapid HM (U/H)
 >>>> 8.9-11.1: 2U actrapid HM (U/H)
 >>>> 11.1-16.7: 3U actrapid HM (U/H)
 >>>> 16.7-27.8: 4U actrapid HM (U/H)
 >>>> >27.8: 6U actrapid HM + inform (U/H)
For HONK (~1/2 DKA)
 - Insulin pump: 49.5mL + 0.5U actrapid HK (1U in 1mL)
 >>>> 4.2-6.7: 0.25U actrapid HM (U/H)
 >>>> 6.7-8.9: 0.5U actrapid HM (U/H)
 >>>> 8.9-11.1: 1U actrapid HM (U/H)
 >>>> 11.1-16.7: 1.5U actrapid HM (U/H)
 >>>> 16.7-27.8: 2U actrapid HM (U/H)
 >>>> >27.8: 3U actrapid HM + inform (U/H)
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8
Q

Thyroid storm

A

Admission

  • NPO
  • Obs q1H
  • Chart IO
  • Foley to BSB q1H
  • Bld x CBC LRFT bone clotting TFT
  • CXR
  • ECG
  • Sputum C/S
  • MSU x stix, C/S
  • Resume usual meds
  • IV 1D1S 500mL q6-8H
  • PO panadol 500mg q4H prn
  • Antithyroid drugs
    &raquo_space;» PO propylthiouracil 150-200mg q6H; 1H after PTU: iodine soln 6-8 drops q8H
    &raquo_space;» IV hydrocortisone 200mg stat, then 100mg q6-8H
    &raquo_space;» PO propanolol 40-80mg q4-6H/ diltiazem 60-120mg q8H
  • Consult ICU
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9
Q

H’stix low

A

Hx

  • Type of DM ; anti-DM drug (CMS vs what the patient is actually using)
  • Indices of glycemic control (HBSM / CGMS, HbA1c, fructosamine)
  • Exact time of onset
  • Known trigger (Reduced appetite? Skipped meal? Poor DM control? forced dietary compliance during hospitalization, CMS Rx wrong, deteriorating RFT, critical illness, liver fail, adrenal insuff, insulinoma), Severity (self-help ability)

Mx
- DAT patients
T2DM
- OAD: stop OAD +- Dextrose drip till full recovery, CBG >10 then restart OAD at lower dose
- (OAD t1/2: diamicron 10H, diamicron MR 16H)
- Insulin: stop insulin till expected insulin effect finish, then restart at lower dose
T1DM/ T1 behavior (pancreatectomy, chronic pancreatitis, DKA, chronic DM requiring basal insulin)
- NEVER w/h BASAL INSULIN

Step down DM drugs

  • step down insulin first
  • NOT sudden w/h
  • NPO patients
    T2DM
  • (low dose OAD) IVF 1/2 1/2 500ML + Q4H sliding scale
  • (high dose OAD) DKI drip: IVF D5 500mL + 6-8U/pint + 0-10mmol KCl + q4H sliding scale
  • titrate against h’stix/rft
    T1DM
  • DKI drip: D5 500mL + 6-8U/pint + 0-10mmol KCl + q4H sliding scale
  • Oral / IV dextrose till >4mmol/L
  • IMi glucagon if no drip site
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10
Q

DM clinic

A
  1. DM ABC: A1c, bp, cholesterol
  2. Think about oral hypoglycemic drugs before insulin
    - top up drugs before consider using another
    - biguanide
    &raquo_space;»> metformin: 500 BD / 850 daily to 850 BD/ 1gBD; renal adj (eGFR <=45; <30 contraindicated); SE: diarrhea, flatulence, nausea, vomiting, chest discomfort/ palpitation, metallic taste, dyspnea
  • sulphonylurea: stim insulin release from pancreas
    &raquo_space;» diamicron (gliclazide): 40-80mg daily to 80-320mg daily; renal adj (severe = contraindicatied) AND heart failure; SE: hypoglc, HTN/angina/edema, headache/dizziness/insomnia, hyperglc/hyperlipid, diarrhea, UTI, viral infection, LDH/Cr

> > > > daonil (glibenclamide): 2.5-5mg/day to 1.25mg to 20mg per day (increase 2.5mg /d at weekly interval); not recommended in renal impairment; SE: epigastric fullness, heartburn, nausea, HS

  • sglt2 inhibitor (glifozin): dec reabs at proximal renal tubule
    &raquo_space;» dapaglifozin: 5mg/day to 10mg/day (after 4-12/52); GOOD FOR HF; renal adj (eGFR <30 contraindicated); SE: dyslipidemia, nausea, UTI, genitourinary fungal infection; back pain, nasopharyngitis, perianal necrotizing fasciitis, multiple insulin injection in small dose, prone to ketoacidosis
  • DPP4 inhibitor (gliptin): inc incretin (e.g. glucose like peptide 1) inc pancreatic insulin secretion
    »» alogliptin (cheap): 25mg daily; renal adj (<15 - <30: 6.25mg daily); SE: arthralgia, bullous, PANREAS
    »» linagliptin ($$$): 5mg daily; NO renal adj!; SE: hypoglc, lipase (PANCREAS), nasopahryngitis
    »» saxagliptin: 2.5 - 5mg daily; renal adj (2.5mg daily) and PANCREAS; SE: edema headache, hypoglc, UTI
  • Thiozolidinediones: insulin sensitization
    »» actos (pioglitazone): 15-30mg daily (max 45mg daily); renal adj AND heart fail; edema/cardiac failure, hypoglc, upper resp tract infection, fracture
    »»
  1. Insulin adj
    How to read HBSM
  2. prebreakfast
  3. prelunch
  4. predinner
  5. fasting midnight
    Insulin start dose: 0.1U/kg, if fasting glc high then +1 degrees (<7)
    Long acting insulin: glargine, protaphane, degludec
    Short acting insulin: aspart, lispro
    Mixtard (70% long acting 30% shortacting)
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11
Q

DM new case

A

Polyuria, polydipsia, weight loss despite polyphagia
DM Hx: family history, IFG/IGT, GDM
RF: metabolic syndrome, obesity, HT, dyslipidemia, smoking, PCOS, LT steroid
Cx:
- retinopathy, nephropathy, neuropahty
- stroke, CAD, PVD
- infection
- vulval candidiasis, GDM, macrosomia
- acute: HHS (dec appreciation of thirst, diuretics, depression of sensorium, dehydration), DKA (due to poor compliance/ infection/ OT/ trauma/ emo/ MI/ stroke/ drug; lethargy, dehydration, kussmaul brething, altered consciousness, n/v, abd pain), hypoglc (excess insulin, insuff carb e.g. diet/alcoholic, renal impair; palpitation/sweating/tremor/anxiety, hunger/paresthesia, behavioral change/consciousness/seizure)

FG, OGTT, HbA1c
FG>7
2H OGTT >11.1
RG >11.1 + classic sx of dm
HbA1c >6.5%
ALWAYS CONFIRM BY repeating test
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Houseman (break your leg) (23 decks)

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