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Emergency Medicine Assistantship > Endocrine Emergencies > Flashcards

Endocrine Emergencies Flashcards

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1
Q

Is DKA a condition that affects just T1 diabetics?

A

No - rarely it can affect T2 diabetics as well.

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2
Q

What is DKA?

A

Diabetic ketoacidosis is a medical emergency caused by uncontrolled lipolysis, resulting in excess free fatty acids which convert to ketone bodies.

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3
Q

What is the classic triad of DKA?

A

Hyperglycaemia
Acidosis
Ketonaemia/Ketonuria

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4
Q

How common is DKA?

A

4% of T1 diabetics experience DKA each year

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5
Q

What might precipitate DKA?

A
  • Infection
  • Discontinuity of insulin
  • Inadequate insulin
  • Cardiovascular event/disease
  • Drugs
  • Other physiological stress
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6
Q

Which drugs are often precipitants of DKA?

A

Steroids
Thiazide diuretics
SGLT2 inhibitors

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7
Q

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?

A

DKA

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8
Q

What might be different about the breathing of a pt who is in DKA?

A
  • Deep hyperventilation

- Acetone/pear drop smell on the breath

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9
Q

Why do pts with DKA get deep hyperventilation?

A

To try and compensate for metabolic acidosis with respiratory system.

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10
Q

What signs of gross dehydration might a pt in DKA have?

A
  • Dry mucuous membranes
  • Decreased skin turgour
  • Sunken eyes
  • Slow cap refil
  • Tachycardia with weak pulse
  • Hypotension
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11
Q

Which part of the initial assessment is most important in identifying DKA?

A

D - doing blood glucose.

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12
Q

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?

A
  • Alcoholic ketoacidosis
  • Hyperosmolar hyperglycaemic state
  • Other metabolic acidosis
  • Sepsis
  • Acute abdomen is painful abdo
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13
Q

What are the Joint British Diabetes societies diagnostic criteria for DKA?

A
  • Glucose > 11 mmol/l or known diabetes
  • pH <7.3
  • Bicarb <15 mmol/l
  • Ketones >3 mmol/l OR ++ ketonuria
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14
Q

What might indicate to you that a case of DKA is severe?

A
  • Ketones >6
  • Bicarb <5
  • pH <7.0
  • GCS under 12
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15
Q

How should DKA be managed?

A
  • Initial resus as required
  • Call for senior help
  • Continuous monitoring
  • IV access
  • Follow DKA trust guidelines
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16
Q

What is the most important initial intervention in DKA?

A

Fluid replacement followed by insulin administration

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17
Q

What is the recommended insulin infusion rate for DKA?

A

0.1 units/kg/hour

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18
Q

What is the most important electrolyte imbalance casued by DKA?

A

Hypokalaemia

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19
Q

What kind of monitoring do pts who have had DKA need?

A

HDU/ITU continuous monitoring with review of all clinical aspects at frequent intervals.

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20
Q

What rate should blood glucose be corrected in DKA management?

A

Reduce by 3-5 mmol/L/hour until <12 mmol/L, then add 5% dextrose to saline to continue insulin therapy

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21
Q

What are the complications of DKA?

A
  • Cerebral oedema
  • Pulmonary oedema
  • Hypoglycaemia
  • Hypokalaemia
  • Cardiac dysrhythmia
  • VTE
  • ARDS
22
Q

What is more likely to occur in pts with T2DM than DKA?

A

Hyperosmolar hyperglycaemic state

23
Q

What is an adrenal crisis?

A

Acute deficiency of cortisol and aldosterone.

24
Q

When does an adrenal crisis occur?

A

When hormonal demand exceeds the ability of the adrenal glands to produce these hormones, most commonly when there is intercurrent illness or stress.

25
Q

What is a common iatrogenic cause of adrenal crisis?

A

Abrupt withdrawal of steroids.

26
Q

What is the largest risk factor for adrenal crisis?

A

Long term steroid therapy, mostly oral.

27
Q

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?

A

Dehydration
Hypotension
Hypovolaemic shock
LoC/coma

28
Q

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?

A

Na low end of normal
K high end of normal
Creatinine and urea raised

29
Q

Should treatment be started before or after confirmation with cortisol and ACTH tests if adrenal crisis is supected?

A

Before - it won’t do any harm if it turns out to be something different and steroids will save their lfe if it is.

30
Q

Which steroid needs to be given ASAP if a pt is in an adrenal crisis?

A

Hydrocortisone either IV or IM

31
Q

What are the elements of management to an adrenal crisis?

A

Hydrocortisone
IV normal saline
Monitor U&Es and ECG and glucose
Treat the cause

32
Q

What immediate dose of hydrocortisone should be given for an adult in adrenal crisis?

A

100mg

33
Q

What maintenance dose of hydrocortisone should be given for an adrenal crisis once the pt is rehydrated?

A

100-200mg hydrocortisone in 5% glucose over 24 hours

34
Q

What is HHS?

A

Hyperosmolar hyperglycaemic state is hyperglycaemia usually over 40 mmol/L due to illness, dehydration, and instability of normal medication regime.

35
Q

What are the characteristics of HHS?

A

Hyperglycaemia
Serum hyperosmolarity
No significant ketosis

36
Q

How does hyperglycaemia cause hyperosmolarity in HHS?

A

It causes osmotic diuresis

37
Q

Why does ketosis not occur in HHS?

A

T2 diabetics have basal insulin levels that are sufficient to prevent ketogenesis, but no sufficient to reduce blood glucose.

38
Q

How quickly does HHS usually progress?

A

Very wuickly - pt becomes very ill and dehydrated very fast

39
Q

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?

A

HHS

40
Q

What are the vitals like for a pt who has HHS?

A 
Hypotensive
Tachycardic
Low AVPU/GCS
Postural drop
Tachypnoeic
Deranged temperature (either way)
Low Sats
41
Q

What is a major differential for HHS in older patients?

A

delirium

42
Q

If a patient who is not known to be diabetic presents with similar symptoms to HHS, what might be suspected?

A

Acute poisoning

Intentional overdose

43
Q

What results are found on urinalysis of a pt with HHS?

A

Marked glycosuria but normal or only slightly raised ketones

44
Q

What are the goals of treating HHS?

A
  • Treat the cause
  • Normalise osmolality safely
  • Replace lost fluids and electrolytes
  • Normalise blood glucose
  • Prevent complications
45
Q

If a patient is suspected to have HHS, how should they initially be manahed?

A

ABCDE assessment inc. catheter and transfer to ITU considered.

Alert the diabetic/acute medical team.

46
Q

What is the principle fluid used in HHS and what does it do?

A

IV 0.9% saline (NaCl) to restore circulating volume and reverse dehydration

47
Q

What is the fastest rate that hypernatraemia can be reversed?

What does thi smean for HHS patients?

A

10 mmol/L in 24 hours

IV fluid replacement needs to be monitored with regular U&Es.

48
Q

How much fluid replacement is given to patients who have HHS?

A

3-6 litre in first twelve hours, then remaining estimated loses over subsequent 12 hours.

49
Q

What are the possible complications of HHS?

A
  • Ischaemic organ damage e.g. stroke/MI
  • DVT/PE
  • ARDS
  • DIC
  • Rhabdomyolysis
  • Cerebral oedema
  • Central pontine myelinolysis
50
Q

What is the mortality rate associated with HHS?

A

15-20%

Emergency Medicine Assistantship (12 decks)

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