Endocrine Emergencies Flashcards
Pathophysiology of DKA
Body's response to cellular starvation Relative insulin deficiency Counterregulatory excess (glucagon)
Why does one become acidotic in DKA?
Relative insulin deficiency
Cellular starvation
Lipolysis with subsequent fatty acid transport to hepatocytes
Formation of ketoacids
Ketonuria
Anion gap metabolic acidosis with capensatory tachypnea
Vomiting
Why does one become dehydrated in DKA?
Relative insulin deficiency
Hyperglycemia increases osmotic load and leads to glycosuria
Water drawn out of cells via oncotic pressure
Impaired consciousness
Shock
Presentation of DKA
Hyperglycemia
Acidosis from ketoacids
Volume loss
Presentation of Hyperglycemia
Polydipsia
Polyuria
Presentation of Acidosis from Ketoacids
Tachypnea
Fruity odor of breath
Signs of Dehydration
Dry membranes
Poor skin turgor
Delayed capillary refill
Mental confusion
Management of DKA
Aggressive fluid therapy (NS) Place monitor 2 large bore IVs Bedside glucose, urine dipstick, EKG CBC, CMP, phosphate, and magnesium ABGs Blood cultures/other labs as indicated
Fundamentals of Treatment of DKA
Volume repletion
Reversal of metabolic consequences of insulin insufficiency
Correction of electrolyte and acid-base imbalances
Treatment of precipitating cause
Avoid complications
Why does fluid administration help with a decrease in blood glucose and ketone concentration?
Increases GFR
Allows for glucose and ketones to be excreted
Insulin Therapy in DKA
0.1 units/kg/hr after fluid bolus
Use infusion pump for less complications, flexibility in adjusting dose
AVOID IM and subQ doses
What is the most life-threatening electrolyte derangement during treatment of DKA?
Hypokalemia
Goals of Potassium Therapy in DKA
Maintain normal extracellular K during acute phase
Replace intracellular K over several days
Hypokalemia in DKA due to Therapy
Cardiac arrhythmias
Respiratory paralysis
Paralytic ileus
Rhabdomyolysis
Complications of DKA
Hypoglycemia Cerebral edema Hypokalemia Hypophosphatemia Adult respiratory distress syndrome
Reasons for DKA in NOT a New Onset Diabetic
Compliance issues
Discontinuation of insulin
Insults to the body such as infection, MI, PE
What condition occurs in patients with poorly controlled or undiagnosed type II DM?
Hyperosmolar hyperglycemic state
Define Hyperosmolar Hyperglycemic State
Serum glucose: 600+ mg/dL Plasma osmolality: 315+ mOsm/kg Bicarbonate: 15+ Arterial pH: 7.3+ Serum ketones negative
Shared Symptoms of DKA and Hyperosmolar Hyperglycemic State
Hyperglycemia Hyperosmolality Severe volume depletion Electrolyte imbalances Acidosis??
Mortality Rates in DKA and Hyperosmolar Hyperglycemic State
DKA: 5%
HHS: 15-30%
Risk Factors of Hyperosmolar Hyperglycemic State
Inability to access water
Non-ambulatory patients
Presentation of Hyperosmolar Hyperglycemic State
Elderly Abnormalities in vitals or mental status Precipitated by acute illness \+/- baseline cognitive impairment Weakness Anorexia Fatigue Cough Dyspnea Abdominal pain
Treatment of Hyperosmolar Hyperglycemic State
Volume repletion Correction of electrolyte abnormalities Treat precipitating cause Correction of hyperglycemia Judicious management of concurrent illness
Neurogenic (Increased ANS Activity) Hypoglycemia Signs and Symptoms
Sweating Pallor Tachycardia Palpitations Tremor/shaking Nervousness/anxiety Tingling, paresthesias
Neuroglycopenic (Lack of Sugar to Brain) Hypoglycemia Signs and Symptoms
Headache Drowsiness Lightheadedness or syncope Mental dullness or confusion Amnesia Seizure Coma
At what glucose level do neurogenic symptoms appear?
Approximately less than 54 mg/dL
At what glucose level do neuroglycopenic symptoms appear?
Approximately less than 47 mg/dL
Define Hypoglycemia Unawareness
Development of low serum sugar values without physiologic ability to react
Patients at Greatest Risk for Hypoglycemia Unawareness
Extremes of age
Co-morbidities
Medications
Outpatient Recommendations for Treatment of Hypoglycemia
15-20 g of glucose
Retest glucose in 15 minutes
Prescribed glucagon
Alter insulin or dosage adjustment of oral medication
ED Management of Hypoglycemia
1 g/kg body weight dextrose Retest glucose q30 for 2 hours Oral replacement (300g) Glucagon 1 mg IM/IV Octreotide
Other Considerations for Hypoglycemia in Non-Diabetic Patients
ETOH
SEpsis
What does the adrenal medulla secrete?
Epinephrine
Norepinephrine
What does the adrenal cortex secrete?
Mineralocorticoids (aldosterone)
Glucocorticoids (cortisol)
Sex hormones
Function of Adrenocorticotropic Hormone (ACTH)
Stimulate synthesis and secretion of adrenocortical hormones
Define Adrenal Insufficiency
Failure of adrenal glands to produce essential BASAL secretion of steroids
Symptoms of Insidious Wasting Disease in Adrenal Insufficiency
Weight loss Fatigue Lack of ambition Hypotension Hyper-melanoma
Define Adrenal Crisis
Failure to RESPOND to the increased demands caused by stress or SUDDEN INABILITY to secrete essential steroids
Define Primary Adrenal Insufficiency
Results from destruction or dysfunction of the adrenal cortex
Define Secondary Adrenal Insufficiency
Results from inadequate stimulation of adrenal cortex by ACTH
Where is adrenal crisis seen?
Undiagnosed primary adrenal insufficiency subjected to major stress
Known adrenal insufficiency who doesn’t take extra steroids during major stress
After bilateral adrenal infarction or hemorrhage
Presentation of Adrenal Crisis
Marked hypotension
Abdominal and flank pain
Treatment of Adrenal Crisis
IV glucocorticoids
D5NS: correct hypovolemia and hypoglycemia
Signs and Symptoms of a Pheochromocytoma
Episodic or sustained Palpitations Sweating Headaches Fainting spells HTN emergencies
Key History of Pheochromocytoma
Episodes of HTN, headache, palpitation, and sweating
Diagnosing a Pheochromocytoma
Demonstrating elevated urinary excretion of catecholamines or metabolites DURING a hypertension period
Lab Levels in Hypothyroidism
TSH: high
T4, T3: low
When does myxedema occur?
In individuals with long-standing preexisting hypothyroidism presents with life-threatening decompensation
Most Common Patient Population
Geriatric patients
Presentation of Myxedema
Alteration in mental status Hypothermia Bradycardia Hypotension Hypoventilation Cardiovascular collapse Decreased drug clearance History of primary hypothyroidism, previous thyroid surgery, or hypercholesterolemia
What is myxedema coma generally preceded by?
Medication non-compliance
Cold exposure
Severe infection
Addition of new medications
Laboratory Findings in Myxedema Coma
Anemia Hyponatremia Hypoglycemia Elevated transaminases Elevated CPK Elevated lactate dehydrogenase Hypercholesterolemia Decreased PO2 Increased PCO2
Treatment of Myxedema Coma
Stabilization Correction of hypothermia (passive external rewarming) IV levothyroxine Routine administration of glucocorticoid Gentle fluid restriction
Hyperthyroidism Symptoms
Heat intolerance Palpitations Weight loss Sweating Tremor Nervousness Weakness Fatigue
What is a thyroid storm potentially preceded by?
Infection Trauma DKA MI CVA Thromboembolic disease Surgery Withdrawal of thyroid medications Iodine administration
Symptoms Seen in Thyroid Storm but not Hyperthyroidism
Fever
Arrhythmias
CHF
CNS dysfunction: agitation, confusion, delirium, stupor, coma, seizure
Treatment of Thyroid Storm
Stabilization
Beta-blockers: severe adrenergic symptoms
Antithyroid agents
Iodine: decrease preformed thyroid hormone
