Endocrine Flashcards
What is hypopituitarism?
Which hormones?
Not enough hormones from the pituitary
GH - main one
Gonadotropin
TSH
Corticotropin
In hypopituitarism, what are GH levels at first?
If GH is low, will this affect their growth?
Normal. They drop around 1 yr or at the growth curve.
- But they still are having this hormone. Just not enough
Yes - duh.
In hypopituitarism, what can occur if Gonadotropin levels are low?
What type of issues can arise with low TSH & corticotropin?
Delayed sexual development
- difficulty reproducing
Developmental issues as well.
What will the bone age be in someone with a low GH level?
Bone age will be delayed
- growth plates will not be developed like they should be for age
When a child isn’t growing like expected & we think it is GH - how do we diagnosis this?
- Check family history to see how other members grew. Combination between parents is typical.
- Check for tumors that interfere with production
- X rays to look at the bone age
If GH is low - what things can stimulate GH production?
Explain the last one
Arginine, L-dopa, and Insulin (hypoglycemia will stimulate it).
Percent of GH cases that are successfully treated when the GH is replaced?
Type of injection used to replace GH?
What is a reason to stop administering the GH?
80% of GH cases
- this means they get “closer” to expected growth
SQ for 6-7 days a week
Stop GH if the bone plates are closing bc it is the maximum
- they will monitor for this
Why do we test kids who have GH deficiency for other hormones?
Just incase they have other deficiencies & to get them those supplements.
- TSH, Gonadotropin especially
Why is family support so important with GH therapy?
It is expensive. Need to make sure the family has the resources.
- help with insurance
Also, children can go through personality changes that the family may not be expecting.
Also help child feel accepted in society.
What is Diabetes Insipidus?
And what does this cause?
Undersecretion of Antidiuretic Hormone (ADH)
- ADH will decrease if there is an excess of fluid and it will increase when there’s too little fluid.
- Just think of the name.
Diabetes Insipidus. Since we don’t have enough ADH, you will have excessive urination and thus dehydrate yourself.
- and restricting fluid won’t help
How to diagnose Diabetes insipidus (or too little ADH = dehydration)?
What can cause DI? How does this affect treatment?
Clinical manifestation of excessive urination
Tumor of or near the pituitary.
Trauma or infection.
- If one of these things are the cause, then we need to treat this first.
What can vasopressin do for Diabetes insipidus?
What route is it given?
If vasopressin is given in then the urine excretion will stop.
It is sort of a definite sign or test that Diabetes insipidus is the problem in the first place.
- vasopressin is actually a synthetic ADH
Give vasopressin IV, orally, nasally
- DDAVP
What if the cause of Diabetes Insipidus isn’t due to a tumor/infection that can be fixed? How will they be treated?
They’ll be given long term therapy for ADH replacement.
- maybe vasopressin long term?
What is Syndrome of Inappropriate Antidiuretic Hormone?
What electrolyte is affected?
What happens to urine osmolality?
SIADH is just an overproduction of ADH.
- meaning you won’t pee & you will retain fluid
Sodium (Na) will dilutionally decrease
Urine osmolality increases.
Since SIADH causes a decrease in sodium, what can that cause?
How to manage this?
Can cause Neurological changes due to cerebral edema (can cause brain damage due to pressure restricting bloodflow)
- the more sodium decreases, more CNS issues arise
Fluid restriction to make sure it doesn’t make it worse.
Do electrolyte replacement to replace or even draw Na back in.
What is hypoparathyroidism?
Which hormones?
Deficiency in hormones from parathyroid.
Parathyroid hormone (PTH) which help regulate serum calcium -PTH, calcitonin, VIT D will
What can cause hypoparathyroidism?
What is the PTH, Ca, phosphorus relationship
Congenital
Post thyroidectomy (for hypothyroidism or nodules) due to close proximity anatomy - leading to short term impact on PTH
Transient PTH deficiency from mom to neonate
- tremors & seizures due to low calcium
If not enough PTH - will see a decrease in serum Ca and increase in phosphorus
- just regulate and return these to norms
Calcium Levels
Newborn
24-48 hrs old
4-7 yrs old
Child
Ionized
Newborn
24-48 hrs old
Thereafter
Calcium Levels
Newborn 9-10.6
24-48 hrs old. 7-12.0
4-7 yrs old. 9-10.9
Child 8.8-10.8
Ionized.
Newborn. 4.3-5.1
24-48 hrs old. 4.0 -4.7
Thereafter 4.8-4.92
How to recognize hypocalcemia?
How to treat hypocalcemia?
Tremors, seizures, or any changes in muscle functioning
EKG changes
Treat w calcium replacement IV (later on oral)
As well as replace vitamin D IV to help with calcium absorption
- stay away w scalp veins & monitor their EKGs
Which diabetes is more common in children?
Type 1 since it is an autoimmune process with genetic predisposition.
- However, type 2 is growing since obesity is becoming more common.
For type 1 diabetes to occur in a child, what needs to happen?
What is the patho?
Often need an environmental trigger of some sort like an infection or exposure to chemical. Not really known for sure. We just know its not just genes.
- one time they tried to use immunosuppresants in a study to stop it from happening but it didn’t work
Destruction of beta islet cells in the pancreas
- insulin is produced in these & so then there is a lack of insulin since there’s no cells to make it
- insulin resistance
3 P’s associated with diabetes type 1?
Polyruia - increased urination
PolyDipsia - thirst
Polyphagia - hunger, leading to weight loss
- we often bring someone into the doctors for a prolonged issue like this & they find they have elevated BG and then have diabetes.
- may be DKA too
What is Diabetic Keto acidosis?
How does this happen?
Type 1 diabetics can develop this.
- Changes in breathing
- Fruity smell
- Change of consciousness
Well the 3 P’s kind of set this off due to BG. DKA is often the first finding that causes someone to know they have diabetes type 1.
Can a type 1 diabetes who is already diagnosed and treated develop DKA?
Yes.
Infection/Illness can cause the DKA
Poor diet control and BG climbing & thus burning fat cells (keto)
Stress
Patho of Diabetic Keto Acidosis (DKA)
Glycogen
Glycogenesis
Gluconeogenesis
Explain how they work together
Normal: insulin allows glucose to come on in and feed the cell with energy
- carbs is usually the source of glucose for immediate use
Glycogen: stored carbs in liver in the form of glucose
Glycogenesis: creating the glycogen
Gluconeogenesis: stored proteins and fats as glycogen
Body will usually put carbs in the liver as glycogen. This process if called Glycogenesis. Gluconeogensis is when we put fats & protein into a form of stored glycogen also. (All this means is that we have energy stored away in liver, fat, and muscle. First one to get used up is in the liver)
If we aren’t getting enough glucose in the form of carbs to keep up with energy needs, we burn through all of the stored energy. IF it gets to the point we are using the fats and proteins as energy, our body will give off ketones. Once ketones reach our blood, then we become in a state of acidosis. And we aren’t made to be in an acidotic state & so our body will try to correct it
What are symptoms of DKA…..
Fluids?
Cardiac?
Weight?
Breath?
What may someone mistake them as?
F&E imbalances
Dehydration
- due to wanting to pee out the acid so much
Tachycardia
Hypotension
- trying to compensate for less volume but eventually the tachy stops working to compensate
Kussmauls
- deep respirations trying to blow off CO2 (acid)
Weight loss
- not getting nutrients to cells & the polyphagia
Fruit/acetone breath
- due to ketones
Decreased senses and neuro
- someone might actually think they’re drunk
What can DKA progress to?
Coma & death
- emergency situation
Diabetic Keto Acidosis labs (DKA)
Potassium
Sodium
BUN
Chloride
Phosphurus
Ca & Mg
Co2
Blood sugar
WBC
Triglycerides
DKA
Potassium can be normal or low
- Low due to intracellular changes
Sodium serum level low
- due to diuresis or peeing
BUN increased
- dehydration
Chloride
- normal, low , or high
- saline resuscitation may reason for increased CL
Phosphurus is low
- diuresis
Ca & Mg decrease
- the decrease comes from phosphorus replacement
CO2 will be low now
- due to them trying hard to breath it off
Blood sugar
- elevated
WBC shift left is change is triggered by infection
Triglycerides are elevated
- Very important to monitor these labs DURING treatment. Increased neuro problems with shifting fluid - even if intentional.
Why and when do we want to monitor DKA labs so closely?
We want to monitor labs during treatment especially. This is because our treatment may include fluid shifts - and if this happens too fast, we can have some neuro issues due to cerebral edema. Even if it is intentional, the shift cannot be all of a sudden. It takes time.
If child comes in & they’re admitted for DKA - what are the first initial assessments we want to do?
First check their airway & respiratory needs to see if they’re breathing okay. Next assess for perfusion by checking extremities doing cap refill, checking pulses.
Next lets move to their level of consciousness. Do they seem well put together?
Also - was there a Diabetes type 1 trigger that led to the DKA?
What is the goal if DKA treatment?
Getting them back to normal state really. And controlling their glucose levels.
What type of fluid replacement is needed with DKA?
Isotonic fluids such as a normal saline usually. Could also see Lactated Ringers due to potassium formula without chloride.
- If they have increased chloride essentially.
- Could also use a less isotonic NS mix. Depends on initial lab values & electrolytes
When giving fluids for DKA - what is the goal?
How quickly can we do this?
Need to give them their maintenance fluid needs but also for their losses. This will be a large amount.
Needs to be done over time so we don’t cause fluid shifting to be too fast and cause cerebral edema.
Your patient is DKA. You are giving them NS first but when you see their blood glucose lower to 250, what fluid do you switch to? And why?
Dextrose
So we don’t lower their Blood Glucose too much to where they are hypoglycemic. The dextrose is a carb source and can fuel their cells just enough to keep you balanced.
At what time do you begin giving insulin replacement?
What type of insulin will you use? What is the infusion rate?
Will we ever lower the infusion rate?
Same time as fluid replacement we will start a short acting insulin at 0.05U/kg/hr.
Yes, we will lower the infusion rate of insulin as glucose levels lower. Won’t go lower than 100mg/hr though due to possible fluid shift & edema.
What does insulin have a strong affinity for? What does this mean for us?
Plastic so we need to prime the tubing we plan to use really well. Otherwise, the insulin will bind to plastic instead of going to patient.
After the glucose levels have lowered and acidosis stage has passed we will then switch to giving the patient a SQ insulin. Does this mean we turn off the pump?
No - we will keep the pump going for about 30 min just to make sure the insulin has time to be effective.
Since there’s overall depletion of potassium in the cells (there’s a complicated explanation here), when should we replace this?
What should we monitor for?
Replace Potassium as soon as urine output is established.
Make sure their serum potassium doesn’t drop tho since most of it will get eaten up by the cells.
Monitor for dysrhythmias.
DKA causes low phosphate alterations.
What energy process needs phosphate?
How does it affect oxygenation?
In what form do we replace phosphate with?
ATP needs the phosphate.
Hemoglobin and oxygen binding mechanism to help with perfusion requires phosphate.
Replacement of phosphate is done with Potassium Phosphate.
- watch for hypocalcemia since the phosphate and calcium share inverse relationshipo
Why is lab so important in DKA?
Initial assessment?
Why might we use an NG tube for DKA?
It makes sure treatment is going well. And that there’s no shifting too quickly.
Need to be able to do initial assessment quickly in order to get those IV’s started (NS/LR/Dex + Insulin)
NG tube to decompress stomach & prevent aspiration and vomiting
Can DKA cause respiratory status problems?
What if the infection was the DKA trigger?
How big of a needle are we going to use for IV? And how many sites?
Yes respiratory is a big concern here. They may have loss of consciousness combined with altered breathing and may need to be ventilated.
For infection - we may go ahead and start IV antibiotics too along with fluids and insulin.
As big of a needle as the vein can handle. Two IV sites preferred (usually antecubital)
Why do we monitor urine in DKA?
Check glucose and ketones spilling
What frequent check should we do in a DKA situation?
Labs to check frequently?
Neuro Checks
Vital signs every 1-2 hr
EKG due to cardiac function
Metabolic profile
Blood glucose hourly
I&O - if patient is unconscious will have to use foley catheter to measure
After being treated for DKA what do we need to educate patient on?
If they had DKA that means they likely are Diabetic. We will have to do teaching on Diabetes on new diagnosis.
Even if it is someone who was already diagnosed, follow up and make sure their insulin dose is appropriate for them incase it wasn’t.
How often should you check for signs of cerebral edema from DKA fluid shift ?
What signs are there?
Check Hourly
They may complain of headache. Start to seem a little off or decreased consciousness due to decreasing sensorium.
Check the eyes for papilla edema or optic nerve swelling.
Check for pupil changes.
Cardiac may look like bradycardia & hypertension.
Diabetes insipidus due to pressure from edema altering pituitary functioning.
Why might we use sodium bicarb?
To correct pH if acidosis is severe enough. Less than 7.0 only
- This always needs to be diluted for administration
Desired lab outcomes
BUN
CBC
ABGS
Serum Co2
BUN to decrease as we give them fluids
CBC not look suspicious due to infection treatment
ABGS so ph, co2 will go back to normal levels
Serum co2 should rise back up due to the blood being able to buffer
Requirements needed for us to switch from IV insulin to SQ and thus patient is able to treat themselves?
Acidosis is treated so no ketones spilling into urine either
They must be able to tolerate PO feedings
Blood glucose must be below 180
Other hormones affected by DKA?
Glucagon , adrenaline, cortisol, GH
If an insulin is a mix between short and long acting, what should you be super cautious of?
Do not contaminate the long acting with short acting.
- draw up short acting first .
Dawn Phenomena
Somogyi effect? What is it caused by?
Dawn Phenomena is when their blood sugar is high in the morning beginning 3 or 4
- need longer or intermediate insulin to get them through the night
Somogyi effect is when there is elevated glucose closer to bedtime & then it drops off during the night
- caused by epi, GH, and corticosteroid hormones
T/F
BG changes are worse in smaller children than bigger children
True. Decreased size always means things go to shit quicker
What is a technique used to keep pediatric patients glucose levels more stable?
Insulin Pump - this helps bc a childs small body is a little more dangerous for experiencing hypoglycemia but we don’t want to permit them to have hyperglycemia in response.
What can cause hypoglycemia?
Increase of activity without increasing calories
Not eating enough
Poor absorption of nutrients
Too much insulin
What two main concerns go on with hypoglycemia?
Adrenergic activity & impaired brain functioning
Adrenergic activity signs of Hypoglycemia
Tachycardia Tremors Sweating Irritability Aggression Hunger
Adrenergic activity = think of someone who has been out in the wilderness surviving with no food, water , and is in survival mode
Impaired Brain functioning due to Hypoglycemia
Drowsy Personality change Confusion Loss of coordination Seizures Coma
Think of someone being drunk or tweeking out due to brain cells not functioning bc of low glucose
Quick carb sources for someone who is hypoglycemic:
60-100
Below 60
What if you treat it and it rises above 60 now?
OJ or 1/2 glass of milk for 60-100
Glucose gel or OJ too if below 60
Make sure to recheck the BG in 15 minutes. And if it is still below 60, try again.
If this is your second snack treat then give a protein source with the carbs.
When is glucagon given? How long does it take? Route?
Why use it?
Given IM when someone is hypoglycemic. But it takes at least 15 min to stimulate liver to release glycogen
It is a sustained response but it isn’t rapid
What type of glucose do want to give if the patient is having severe hypoglycemia as in below 40?
Give IV glucose 25-50% with sterile water (dilution helps enter into bloodstream)
Like if they’re unconscious btw.
What do you need to do if you give a hypoglycemic patient glucose gel in buccal pouch?
Why would you want to do this?
Need to monitor them and their airway
It can be helpful bc buccal route absorbs fairly quickly
How do you fix hypoglycemia at night time?
Give glucose gel or OJ if less than 80.
And do 15 min rule
If the BG rises up to 60 or so then do the protein and carb combo
Main concern here with type 1?
How are infants treated?
Avoid hypoglycemia - especially in infants when treating hyperglycemia.
Infants do oral intake in response to treat hypoglycemia. But we allow hunger to drive thier calorie intake and adjust insulin based off that. Obviously avoid concentrated sweets but include breast milk and formula
Explain needs of sick plan for type 1 diabetic children and infants
Stress of illness increases BS so may need to switch to regular insulin, take bs more frequently, urine checks for ketones of DKA (to treat early), and maintain diet as much as possible
Should we just educate the parents about diabetes?
What to keep in mind w small doses?
Can we make the care less traumatic?
Can kids learn to do their own BS?
What are we trying to reduce?
No educate child too.
Small doses need to be more carefully measured and use the appropriate syringe
It is our job to make care as easy as possible
Yes kids can be taught to do own BS
Try to reduce spikes & falls but also reduce long term effects
Is type 2 diabetes in children that much different than in adults?
What is the patho of type 2?
When does type 2 onset occur?
What other rt occurences happen?
No. It’s essentially the same thing. We just normally don’t think of kids having type 2 but society is shifting to be that way.
Insulin resistance > beta cell defect > prediabetes > type 2 Diabetes
Onset is puberty due to hormones
- obesity, Hypertension, hyperlipidemia
What is the main reason why type 2 diabetes is more prevalent in children
And in which sex is this most common in? What else can this sex develop
Sedentary lifestyle
Females 2: 1 males
- can develop polysystic ovary syndrome too
What cultures/ethnicity is higher risk of diabetes?
African Americans Native Americans Hispanic Americans Asian Pacific islanders
(Basically not white people)
Can diabetes type 2 be genetic?
Yes it can
Mean age for type 2 diabetes diagnose
Avg BMI?
Percent in minority groups
12-14
Average BMI is in 85th percentile
94%
Fasting glucose for type 2 goal
PP goal
Bedtime goal
A1c
Fasting : between 80-100
PP : 100-160
Bed : 100-160
A1c below 7
- But we need to make sure we are not overtreating
Can losing weight help with type 2 diabetes
Yes but will look at diet and cardiovascular risks too
- Body image is a very important factor so try to avoid focusing on obesity but encourage health overall
If someone has a BG over 250 what is treatment?
At what A1c can we wean off insulin of type 2 and just add metformin ?
If above 250, will just give insulin, diet , and exercise
Below 7%
What if someone’s BG is elevated and no symptoms?
Start with diet and exercise to see if it improves
Follow up a1c every 3 months. If below 7 then good
Then we can add metformin
Next, do insulin, TZD, Suflon
Lastly add 3rd med
