Endocrine Emergencies Flashcards
Is DKA a condition that affects just T1 diabetics?
No - rarely it can affect T2 diabetics as well.
What is DKA?
Diabetic ketoacidosis is a medical emergency caused by uncontrolled lipolysis, resulting in excess free fatty acids which convert to ketone bodies.
What is the classic triad of DKA?
Hyperglycaemia
Acidosis
Ketonaemia/Ketonuria
How common is DKA?
4% of T1 diabetics experience DKA each year
What might precipitate DKA?
- Infection
- Discontinuity of insulin
- Inadequate insulin
- Cardiovascular event/disease
- Drugs
- Other physiological stress
Which drugs are often precipitants of DKA?
Steroids
Thiazide diuretics
SGLT2 inhibitors
A pt presents to A&E with polyuria, polydipsia, and vomiting for 12 hours. In the ambulance their GCS dropped from 15 to 13.
What is your top differential?
DKA
What might be different about the breathing of a pt who is in DKA?
- Deep hyperventilation
- Acetone/pear drop smell on the breath
Why do pts with DKA get deep hyperventilation?
To try and compensate for metabolic acidosis with respiratory system.
What signs of gross dehydration might a pt in DKA have?
- Dry mucuous membranes
- Decreased skin turgour
- Sunken eyes
- Slow cap refil
- Tachycardia with weak pulse
- Hypotension
Which part of the initial assessment is most important in identifying DKA?
D - doing blood glucose.
A pt who is not known to be diabetic comes in with polyuria, polydipsia, acute confusion, and vomiting ?DKA. What other differentials might you have?
- Alcoholic ketoacidosis
- Hyperosmolar hyperglycaemic state
- Other metabolic acidosis
- Sepsis
- Acute abdomen is painful abdo
What are the Joint British Diabetes societies diagnostic criteria for DKA?
- Glucose > 11 mmol/l or known diabetes
- pH <7.3
- Bicarb <15 mmol/l
- Ketones >3 mmol/l OR ++ ketonuria
What might indicate to you that a case of DKA is severe?
- Ketones >6
- Bicarb <5
- pH <7.0
- GCS under 12
How should DKA be managed?
- Initial resus as required
- Call for senior help
- Continuous monitoring
- IV access
- Follow DKA trust guidelines
What is the most important initial intervention in DKA?
Fluid replacement followed by insulin administration
What is the recommended insulin infusion rate for DKA?
0.1 units/kg/hour
What is the most important electrolyte imbalance casued by DKA?
Hypokalaemia
What kind of monitoring do pts who have had DKA need?
HDU/ITU continuous monitoring with review of all clinical aspects at frequent intervals.
What rate should blood glucose be corrected in DKA management?
Reduce by 3-5 mmol/L/hour until <12 mmol/L, then add 5% dextrose to saline to continue insulin therapy
What are the complications of DKA?
- Cerebral oedema
- Pulmonary oedema
- Hypoglycaemia
- Hypokalaemia
- Cardiac dysrhythmia
- VTE
- ARDS
What is more likely to occur in pts with T2DM than DKA?
Hyperosmolar hyperglycaemic state
What is an adrenal crisis?
Acute deficiency of cortisol and aldosterone.
When does an adrenal crisis occur?
When hormonal demand exceeds the ability of the adrenal glands to produce these hormones, most commonly when there is intercurrent illness or stress.
What is a common iatrogenic cause of adrenal crisis?
Abrupt withdrawal of steroids.
What is the largest risk factor for adrenal crisis?
Long term steroid therapy, mostly oral.
A patient presents to A&E with general abdominal pain, fatigue, and nausea and vomiting.
If this is an adrenal crisis, what signs and symptoms are to follow?
Dehydration
Hypotension
Hypovolaemic shock
LoC/coma
A patient presents to A&E with general abdominal pain, fatigue, and nausea and vomiting. Some blood tests are done.
If this patient is in an adrenal crisis, what would their U&Es look like?
Na low end of normal
K high end of normal
Creatinine and urea raised
Should treatment be started before or after confirmation with cortisol and ACTH tests if adrenal crisis is supected?
Before - it won’t do any harm if it turns out to be something different and steroids will save their lfe if it is.
Which steroid needs to be given ASAP if a pt is in an adrenal crisis?
Hydrocortisone either IV or IM
What are the elements of management to an adrenal crisis?
Hydrocortisone
IV normal saline
Monitor U&Es and ECG and glucose
Treat the cause
What immediate dose of hydrocortisone should be given for an adult in adrenal crisis?
100mg
What maintenance dose of hydrocortisone should be given for an adrenal crisis once the pt is rehydrated?
100-200mg hydrocortisone in 5% glucose over 24 hours
What is HHS?
Hyperosmolar hyperglycaemic state is hyperglycaemia usually over 40 mmol/L due to illness, dehydration, and instability of normal medication regime.
What are the characteristics of HHS?
Hyperglycaemia
Serum hyperosmolarity
No significant ketosis
How does hyperglycaemia cause hyperosmolarity in HHS?
It causes osmotic diuresis
Why does ketosis not occur in HHS?
T2 diabetics have basal insulin levels that are sufficient to prevent ketogenesis, but no sufficient to reduce blood glucose.
How quickly does HHS usually progress?
Very wuickly - pt becomes very ill and dehydrated very fast
A known diabetic who is in hospital for hip replacemetn becomes drowsy and weak. They start to show signs of a hemiparesis as well as marked confusion.
What endocrine cause could there be for this?
HHS
What are the vitals like for a pt who has HHS?
Hypotensive Tachycardic Low AVPU/GCS Postural drop Tachypnoeic Deranged temperature (either way) Low Sats
What is a major differential for HHS in older patients?
delirium
If a patient who is not known to be diabetic presents with similar symptoms to HHS, what might be suspected?
Acute poisoning
Intentional overdose
What results are found on urinalysis of a pt with HHS?
Marked glycosuria but normal or only slightly raised ketones
What are the goals of treating HHS?
- Treat the cause
- Normalise osmolality safely
- Replace lost fluids and electrolytes
- Normalise blood glucose
- Prevent complications
If a patient is suspected to have HHS, how should they initially be manahed?
ABCDE assessment inc. catheter and transfer to ITU considered.
Alert the diabetic/acute medical team.
What is the principle fluid used in HHS and what does it do?
IV 0.9% saline (NaCl) to restore circulating volume and reverse dehydration
What is the fastest rate that hypernatraemia can be reversed?
What does thi smean for HHS patients?
10 mmol/L in 24 hours
IV fluid replacement needs to be monitored with regular U&Es.
How much fluid replacement is given to patients who have HHS?
3-6 litre in first twelve hours, then remaining estimated loses over subsequent 12 hours.
What are the possible complications of HHS?
- Ischaemic organ damage e.g. stroke/MI
- DVT/PE
- ARDS
- DIC
- Rhabdomyolysis
- Cerebral oedema
- Central pontine myelinolysis
What is the mortality rate associated with HHS?
15-20%
