Endocrine Emergencies Flashcards
Physiology of metabolism in starvation:
_________________ are made as byproduct of fatty acid metabolism and used as energy source especially by the __________________.
The two major ketones are _________________ and ______________.
Ketone production is typically tightly regulated to prevent excessive ketoacid production and _______________.
ketones, brain
acetoacetone and B hydoxybutyrate (BHB)
metabolic acidosis
Pathologic ketonemia
ketones build as acids and spill them out as urine, this increases the anion gap
What is the patho of DKA?
IT MAINLY OCCURS IN DM TYPE I. As levels of insulin decrease, fuel stores are mobilized during fasting, resulting in __________________. Despite the presence of intravascular glucose, in the absence of insulin, counter regulatory hormones take over and cells are unable to use glucose as fuel source > breakdown adipose and muscle (catabolic)
Free fatty acids are converted to _______________ which are ________________ and _____________________ which is converted to __________________.
___________________ is falsely NORMAL due to _________________ from osmotic diuresis
As adipose tissue is broken down, prostaglandins ____________ and ____________ are produced > ________________________ occurs despite profound levels of volume depletion
insulin released which is triggered by glucose ingestion > stimulates liver to take in glucose and store as glycogen > increases lipogenesis > stimulates mm to take up amino acids
HYPERGLYCEMIA
ketones
BHB and acetoacetic acid which is converted to acetone
Potassium, volume depletion
I2 and E2
paradoxical vasodilation
______________ is the primary reason that causes DKA aside from missing an insulin injection.
infection
What are the clinical features of DKA?
the metabolic alterations of DKA tend to evolve within 24 hours.
symptoms:
polyuria and polydipsia
vomiting and abdominal pain
alterations in consciousness
signs:
tachy, orthostasis, hypotension, poor skin turgor, dry mucous membranes
kussmaul respirations
fruity odor on the breath
temporal wasting
How is DKA diagnosed?
You want to be aware of euglycemic ketoacidosis which is glucose ___________________
- blood glucose > 250 mg/dl
- an anion gap > 10 to 12 mEq/L
- a bicarb level <15 mEq/L
- pH <7.3 and indicating metabolic acidosis
- moderate ketonuria or ketonemia
divided into mild, mod, severe states
<250
What is the workup for DKA?
CBC, CMP, note potassium and calcium, phosphate, magnesium, serum osm
assume total body K depletion
assume NA is higher
urinalysis
ABG
ketones-serum vs urine
EKG changes induced by hypo/hyperkalemia
What is the treatment of DKA?
- volume repletion is most important
- correction of electrolyte and acid-base imbalances
potassium-rapid development of severe hypokalemia which is the most life threatening electrolyte derangement during the treatment if DKA (insulin action on K)
- if > 5.2 - cleared to start insulin
- if 3.3 < K < 5.5 and urine output then add 20 to 30 mEQ/L to IV fluids PLUS insulin for at least 4 hours to keep K between 4 and 5 meq/L
- if K < 3.3 hold insulin until replace K > 3.3 - Reversal of metabolic consequences of insulin insufficiency > given insulin
Resolution of DKA =
Avoidance of complications:
K > arrythmia. decrease ____________ and ___________
a serum bicarb level > 15
a venous pH > 7.3 and or a normal calculated anion gap
phos and mag
DKA is triggered at low sugar levels in _________________ so the provider should recognize signs and symptoms of DKA and check a serum ________________ level
pregnancy
BHB
What is the goal of treatment for DKA?
glucose < 200
bicarb greater than or equal to 18
venous pH > 7.3
How to manage DKA in a patient with an insulin pump
assume a problem with the pump, disconnect the pump before starting insulin infusion
if DKA resolves in ED and pump works, then restart pump therapy approx 1 hour before the IV insulin drip instead of SC insulin
In very young children, new onset diabetes and adolescents with DKA, _________________ remains the most common and feared cause of (high rate) mortality. It develops within ___________ hours of treatment
Tx: _____________
cerebral edema
4-12
IV mannitol
________________ occurs in alcoholic patients who enter a period of fasting after a dramatic period of ethanol binging. This results in __________________ and ______________. N/V, abdominal pain, and constitutional complaints are common. Ketosis favors __________ due to ___________ depletion from alcoholism.
Tx:
Improvement will see an increase in ______________
alcoholic ketoacidosis
metabolic acidosis and dehydration
BhB, NADH
Tx: IV fluids, replenish electrolytes, supplemental dextrose
urine ketones
Hyperosmolar hyperglycemic state (HHS) is a progressive _________________ and __________________ found in pts with poor controlled or undiagnosed ______________________ commonly it is a ____________________ illness. It is present mostly in _____________.
hyperglycemia and hyperosmolarity
DM Type II
precipitating
elderly
What are the 3 main underlying factors of hyperosmolar hyperglycemic state (HHS)
insulin resistance/ deficiency
inflammatory state + stress hormones = increased hepatic glucogenesis and glycolysis
osmotic diuresis followed by impaired renal excretion of glucose