Endocrine emergencies Flashcards
A patient presents with hypoglycaemia, if no known hx of diabetes what investigations should be performed before giving the pt glucose?
lab blood glucose and serum saved for insulin and C peptide determination-looking for insulinoma or factitious drug administration.
symptoms and signs of hypoglycaemia?
tingling around the mouth, paraesthesia dizziness hunger visual trouble drowsiness confusion *note signs of sympathetic overactivity, and neuro tachycardia palpitations sweating cold extremities anxiety pallor tremor slurred speech focal neurological defect coma
note hypoglycaemic unawareness in pts with well controlled diabetes who have more frequent hypo episodes and become desensitised to sympathetic activation and so may develop neuroglycopenia e.g. become unconscious, without warning.
which patients are at risk of losing the early warning of hypoglycaemia?
patients with well controlled diabetes who have more frequent hypo episodes
those on beta blockers e.g. post MI, to lower BP, manage AF, manage HF, control symptoms of hyperthyroidism and anxiety.
causes of hypoglycaemia?
fasting:
known diabetic treated with insulin or SU e.g. with increased activity, missed meal, accidental or non accidental OD.
if non-diabetic, EXPLAIN:
EXog-drugs and alcohol-e.g. binge with no food, aspirin poisoning, ACEI, beta blocker.
P-pituitary insufficiency e.g. acute pituitary necrosis
L-liver failure (also heart and renal failure, myxoedema)
A-addison’s disease
I-islet cell tumours-insulinoma, and immune hypoglycaemia e.g. anti-insulin receptor Abs in Hodgkins, and infections-sepsis syndrome, malaria.
N-non-pancreatic neoplasms e.g. fibrosarcoma.
post prandial hypoglycaemia-‘dumping’ in those post bariatric/gastric surgery, and in type 2 DM. prolonged OGTT.
what can U+Es tell us in px of hypoglycaemia?
note hypo more common in diabetic nephropathy. note insulin normally broken down by kidneys, and SUs excreted by the kidneys
CKD can rarely cause hypoglycaemia in non diabetic
how can a pt haven taken intentionally too much insulin be differentiated from pt with an insulinoma?
serum measurement of insulin and C-peptide: if high insulin and low C-peptide then exogenous insulin, high C-peptide and insulin indicate endogenous insulin e.g. insulinoma, or surreptitious drug e.g. sulfonylurea-increases insulin release by antagonising beta cell K+/ATP channel activity, causing decrease K+ current-depolarisation, which then increases Ca2+ entry into cell, which governs fusion rate of insulin vesicles with beta cell membrane, and their release into circulation.
what specific treatment should be given to hypoglycaemic pts with hx of chronic alcohol intake or malnourishment?
IV thiamine 1-2mg/kg, to avoid precipitating wernicke’s encephalopathy.
management of hypoglycaemia?
r/f to hypoglycaemia guidelines:
SA carbohydrate initially needed e.g. 5-7 glucose tablets or 90-120ml lucozade, rpt blood glucose in 10mins. must follow with LA carbohydrate e.g. sandwich or 2 biscuits, following normalisation of blood glucose. if pt cooperative but difficulty swallowing can given gluocogel (hypostop)-put around the mouth.
if unconscious or uncooperative give IV 75ml 20% glucose in 15mins, recheck blood glucose after 10 mins, PO glucose once consciousness regained.
1mg glucagon IM if IV access cannot be obtained quickly or pt at home. not effective in liver disease as poor glycogen stores.
admit as inpatient if cause is LASU or long-acting insulin, and start continuous infusion 10% glucose 100ml/hr.
most important part of initial management of pt with DKA?
IV fluid resuscitation: pt massively dehydrated from osmotic diuresis due to high glucose, pt will die from dehydration BEFORE effects of high ketones-acidosis.
