Endocrine Emergencies Flashcards
Acute Adrenal Insufficiency?
aka Addisonian Crisis
what are the key clinical features of an addisonian crisis?
Hypotension, acute pain (abdomen, low back), hypovolemic shock Vomiting, Diarrhea, dehydration, and altered mental status.
is acute adrenal insufficiency fatal?
yes!!! if left untreated
what can cause adrenal crisis?
infection, trauma, surgery, stress, lymphoma, metastic cancer, amyloidosis, sclerodema, hemochromatosis, or cessation of corticosteroid medications, anything that may cause severe physiologic stress, high dose of corticosteroids,
what is the most important hormone in adrenal crisis?
cortisol
what are the functions of cortisol?
- permissive for the action of Epi and NE on muscles and VB
- Maintainer of glucose- adequate cellular concentrations of the enzymes need to produce glucose btw meals
- decreaser of inflammation- changes of capillary permeability and production of prostoglandings
- fetal development
more things that cortisol does
- increases catabolism in bone and muscle
- breakdown of adipose
- inhibits the immune system, growth, reproduction
- activates protective mechanisms (increases: WBC, Glucose, plasma volume
how does adrenal insuff. cause hypotension?
decrease in aldosterone creates imbalance of Na, K and H20!
causes Na to be lost and K to increase!
hypotension and arrhythmias!
what organisms are associated with adrenal crisis?
H. Flu, S. aureus, Strept. pnu, fungi
medications that can cause adrenal insuffi?
ketoconazole, phenytoin, rimfampin, mitotane, septic shock
laboratory work up for adrenal crisis?
hyponatremia, hyperkalemia, Met Acid, hyopglycemia
serum cortisoll: less than 20 mcg/dL in severe stress or after ACTH stimulation
CBC: anemia, lymphocytosis, eosinophilia (highly suggestive)
TSH
what is diagnostic for adrenal insuff?
ACTH test: determine baseling serum cortisol, then give ACTH 250 mch IVP, then draw a serum cortisol 30 and 60 mins later
increase of less than 9 mch/dL is considered diagnostic
how do you treat acutre adrenal insufficience?
glucocorticoids: dexamethasone
agressive fluid replacement w/ 5-10% IV dextrose and saline solutions
tx of hyperkalemia!!!
fresh frozen plasma
pressors (epi or NE) to combat hypotension
Thyroid storm
extreme hyperthyroidism
what can precipitate a thyroid storm?
illness, sepsis, trauma, surgery, RAI (radioactive iodine), pregnancy
Clinical features of thyroid storm?
high fever, tachycardia, agitation, sweating, tremor, instability, delirium, V, D
what is the treatment for Thyroid storm?
PTU, but monitor for liver dysfxn
IV Na-iodid, iV hydrocortisone, Lugol solution (iodine),
propanolol to alleviate signs and sx
long term- PTU or MMI
what is contraindicated in a thyroid storm?
IV dextrose or oral carbs
what electrolyte disorder is seen with a thyroid storm?
hypokalemia! this will response to propanolol
DKA precipiating factors
the 5 I’s:
insulin deficiency infxn ischemia intra-abdominal process intoxication
presentation DKA
Polydipsia and polyuria
Weakness, dizziness
Anorexia
Visual disturbances
Tachycardia
Hypotension
Warm, dry skin, sunken eyes, dry mucous membranes (more with HHS)
Weight loss (more with HHS)
Tachypnea (more with DKA)
GI symptoms: N/V/D
Decreased mentation, lethargy, confusion and/or delirium
Focal neurological signs such as hemisensory deficits, hemiparesis that mimic CVA, aphasia and seizures.
Fruity odor breath (only with DKA) (bc of ketone)
DKA definition
> 200 mg/dL and
acidosis (pH < 7.3 and/or bicarb < 15)
categories:
Mild: pH < 7.30, bicarbonate < 15 mmol/L
Mod: pH < 7.20, bicarbonate < 10 mmol/L
Severe: pH < 7.10, bicarbonate < 5 mmol/L
pathophysiology of DKA
cells are starving bc not getting glucose (no insulin on board) signals to body that nutrients are needed
-liver makes more glucose and breaks down glycogen so amount of glucose keeps increasing
what does the body start to do when the cells are starving?
use other sources of nutrients
-breaks down proteins and fats (lipolysis) and results in the production of ketoacids
and dehydration and poor perfusion leads to lactic acidosis!
Kussmaul respirations
deep sighing that helps increase the bodys way of compensating for metabolic acidosis- decreases CO2
PE findings of someone in DKA
kussmaul, dehydration, tachycardia, delayed cap refil, abdominal tenderness
what do DKA pts get dehydrated?
osmotic diuresis- kidnesy are overwhelmed by excess glucose that keeps water in renal tubules that leads to increased urination and dehydration
Vomiting!
what electrolyte imbalances are associated with DKA?
hyponatremia and hypokalemai bc the ketoacids bind to Na and K
treatment of DKA
correct dehydration, correct acidosis and reverse ketosis
-correct electrolyte imbalance
give insulin
step 1 of tx of DK
IV hydration!
NS bolus of LR bolus 20 ml/kg over 1 hours (wathc for cerebral edema)
then at maintainence IV fluid rate
why must you be careful when correcting dehydration of DKA pts?
must go slow to avoid rapid shift of water from extracellular to intracellular– cell swelling or cereral edema
step 2 tx of DKA
insulin infusion!
no bolus in kids bc may increase risk of cerebral edema
and switch to D5ND when glucose is < 300 mg/dL
cerebral edema and DKA pts
watch out for in kids!!! (AMS, dilated pupils, decreased HR w/ increased BP)
Reduce rate of IVF infusion
Mannitol 0.5-1 g/kg over 20 min
3% saline 5-10 ml/kg over 30 min (hypertonic saline)
Consider intubation if cannot protect airway
fasting hypoglycemia
occurs secondayr to some endocrine disorders (addison, myxedema), liver malfxn, acute alcoholism, ESRD
what is primary hypoglycemia caused by?
hyperinsulinism, extrapancreatic tumors (insulinoma) or B cell tumors
what is postprandial or reactive hypoglycemia?
early (2-3 hours after eting) vs late (3-5 hours after eating)
- GI surgery (espeically postgastrectomy w/ dumping syndrome or roux-en-Y gastric bypass) can be alcohol related, factictious, immunopahtologic, or drug induced
CF of hypoglyceia?
sx begin at plasma glucose levels of 60 mg/dl
-cognitive impariement at 50
what does fasting hypoglycemia occur with?
neuroglycopenia
what does postprandial hypoglycemia look like?
sweating, palpiations, anxiety, and tremulousness
what is he Whipple triad?
hx of hypoglycemic sx, fasting BG of 45 or less, and immediate recovery when given glucose
