Endocrinology Flashcards
Mild Dehydration (5%)
- Fatigued
- Drinks, but may refuse
- Normal heart rate
- Normal to increased pulses
- Normal breathing
- Normal eyes
- Tears present
- Moist mucous membranes
- Instant skin recoil
- Cap refill normal
- Warm to beginning to cool extremities
- Mildly decreased urine output
Moderate Dehydration (10%)
- Fatigued or restless, irritable
- Thirsty
- Normal to increased heart rate
- Normal to increased pulses
- Fast breathing
- Slightly sunken eyes
- Decreased tear production
- Dry mucous membranes
- Skin recoil < 2 sec
- Prolonged cap refill
- Cool extremities
- Decreased urine output
Severe Dehydration (15%)
- Lethargy
- Unable to drink
- Tachycardia
- Weak pulses
- Deep breathing
- Sunken eyes, sunken fontanelles
- Absent tears
- Parched mucous membranes
- Skin fold recoil prolonged
- Prolonged cap refill
- Cold, mottled, cyanotic extremities
- Minimal urine output
Types of Dehydration
- Isonatremic
- Hypernatremic
- Hyponatremic
Management of Dehydration
- Identify underlying problem
- Replace electrolytes slowly
- Correct fluid losses over 24-48 hours
- Maintenance and replacement fluid infusion
- Monitor intake and output
- Monitor electrolytes
Fluid Dose: 0-10kg
100mL/kg/day
4mL/kg/hr
Fluid Dose: 10-20kg
1000mL + 50mL for each additional kg 0ver 10kg
40mL/hr + 2mL/hr for each additional kg over 10kg
Fluid Dose: >20kg
1500mL + 20mL for each additional kg over 20kg
60mL/hr + 1mL/hr for each additional kg over 20kg
Electrolyte abnormalities
Most common: Hyponatremia, hyperkalemia, hypocalcemia.
Hyponatremia
Causes:
- SIADH, adrenal insufficiency, hypervolemia, hypovolemia, excessive water intake.
Tx: Correct Na at a rate of 0.5mEq/L/hr.
- If symptomatic, NSS 20mL/kg bolus, consider hypertonic saline 3%
Hyperkalemia
Causes:
- Excessive oral/IV intake, decreased excretion (renal failure, beta-blockers, diuretics), acidosis.
- Make sure that potassium values were not hemolyzed.
EKG Changes: Peaked T-waves, depressed ST, wide QRS, no P-wave
Tx: Discontinue diuretics and oral/IV K+, perform EKG, obtain CMP, CPK, UA, ABG, Na bicarbonate and insulin with glucose IV, administer calcium.
- Kayexalate is sometimes used.
Hypocalcemia
Causes:
- Hypoparathyroidism, vit D deficiency, renal insufficiency.
Tx: (Hypoalbuminemia) Correct Ca+ with 0.8mg/dL for each 1g/dL, consider EKG, consider CMP, albumin.
- Calcium replacement with calcium chloride or gluconate.
- If given IV, administer slowly!
Acute Hypoglycemia
Glucose < 50mg/dL - ketotic vs nonketotic
Causes:
- Neonatal - diabetic mom, adrenocortical deficiency, inborn errors, SGA.
- Childhood - Inborn errors, growth hormone deficiency, stress, hepatic dysfunction, ingestion, infection.
Tx: Glucose replacement - 0.5-1g/kg 10% or 25% glucose
Syndrome of Inappropriate Anti-Diuretic Hormone (SIADH)
Excess of ADH with increased permeability of renal distal tubules and collecting ducts, results in increased water reabsorption and decreased urine production.
Causes: CNS injury, diseases of hypothalamus or pituitary, hepatic disease, pulmonary disease, high dose chemotherapy.
S/S:
- Serum Sodium LOW
- Serum Osmolarity LOW
- Urine Sodium HIGH
- Urine Osmolarity HIGH
- Specific Gravity HIGH
- Urine Output low or normal
Tx: Restrict sodium and fluid intake, monitor electrolytes and intake/output, diuretics, 0.9%NS.
Diabetes Insipidus (DI)
Central: Antidiuretic deficit.
- Genetic, congenital, acquired.
Nephrogenic: Adequate levels of ADH, results in decreased water reabsorption, increased urine output, hypernatremia, and dehydration.
- Congenital or acquired as a result of renal disease, metabolic conditions or medication related.
Causes: CNS injury or infection, disorders of the hypothalamus, pituitary or panhypopituitarism after tumor resection, primary and secondary renal defects.
S/S:
- Serum Sodium HIGH
- Serum Osmolarity HIGH
- Urine Sodium LOW
- Urine Osmolarity LOW
- Specific Gravity LOW or NORMAL
- Urine Output HIGH, > 4mL/kg/hr
Tx: Vasopressin or DDAVP, fluid replacement, monitoring of fluids and electrolytes.
Cerebral Salt Wasting (CSW)
Atrial natriuretic hormone excess, results in Na excretion into urine and diuresis.
- Hyponatremia, euvolemia or hypovolemia.
Causes: CNS injury or infection, endocrine disturbances including DKA, chronic lung disease or BPD, cardiac disease.
S/S:
- Serum Sodium LOW
- Serum Osmolarity LOW
- Urine Sodium HIGH
- Urine Osmolarity HIGH
- Specific Gravity HIGH or normal
- Urine Output HIGH, 2-3mL/kg/hr
Tx: Treat underlying problem, replace sodium slowly, maintain fluid intake, monitoring of fluids and electrolytes.
Type 1 Diabetes
Condition in which the pancreas no longer produces enough insulin or cells stop responding to the insulin that is produced, so that glucose levels are elevated and other metabolic problems persist.
S/S: Polyuria, polydipsia, polyphagia, fatigue, and weight loss. Complications of poorly managed diabetes may include cardiovascular disease, diabetic neuropathy, diabetic retinopathy.
Tx: Subcutaneous insulin, short and long-acting.
- Short: 0.5-1 unit/kg/day
Diabetic Ketoacidosis (DKA)
State of insulin deficiency in which a starvation state triggers a cascade of metabolic responses, including hyperglycemia and ketone body formation with lactic acidosis from decreased tissue perfusion resulting in metabolic acidosis.
- Can present with initial diagnosis or throughout lifetime of patient with IDDM.
- pH < 7.3 and HCO3 < 15
S/S: Abdominal pain, vomiting, puolyuria, hyperglycemia, ketonuria, lethargy, and other mental status changes, tachycardia, signs of dehydration, and Kussmaul respirations.
Dx: Glucose, electrolytes, UA, VBG, serum ketones, CBC, LFTs, amylase, lipase.
- Typical findings include increased glucose, low pH, HCO3 < 15, + ketonuria, + serum ketones.
- For newly diagnosed diabetics and children in DKA, a HgbA1c should be obtained, labs should include insulin autoantibodies, insulin level, thyroid function tests, islet cell antibodies, C-peptide levels.
Tx: NS bolus 20mL/kg, begin insulin drip at 0.1 units/kg/hr, add glucose when serum glucose is about 250-300 or if glucose levels are dropping faster than 100/hr, replace potassium, consider buffered fluids such as potassium acetate, replace phosphorus.
- Frequent labs, glucose q1hr, VBG. VS with neuro checks every 1-2 hours, cardiac monitor.
- Convert to subcutaneous insulin when lab values (pH and HCO3) are normalized.
Complications: Cerebral edema - headache, irritability, confusion, seizures, altered LOC, Cushing triad.
Adrenal Insufficiency
Dysfunction of the adrenal gland.
Primary: Congenital Adrenal Hyperplasia (CAH), sepsis, surgical removal, Addison disease, adrenal hemorrhage.
Secondary: Destroyed or inactive adrenal gland, ACTH deficiency.
Tertiary: Suppression from steroids, rapid taper of steroids.
Relative: Critical illness, shock.
Adrenal Crisis
Rapid, overwhelming, potentially fatal situation.
- Occurs with chronic adrenal insufficiency, acute damage, abrupt withdrawal of steroids.
S/S: Hypotension, fatigue, vomiting, muscle pain, anorexia, weight loss.
- With cortisol deficiency - hypotension, hypoglycemia, weakness, anorexia, nausea, vomiting.
Dx: Obtain CMP, glucose, ACTH, am cortisol level and aldosterone concentration.
Tx: Glucocorticoids, monitoring of function.
Congenital Adrenal Hyperplasia (CAH)
Hyperkalemia, hyponatremia, dehydration.
Dx: Serum electrolytes, ACTH stimulating test, cortisol levels.
Tx: Manage fluid and electrolytes, glucocorticoids, hydrocortisone.
Thyroid Storm
Life-threatening condition due to untreated hyperthyroidism.
S/S: HTN, fever, ALOC, tachycardia, sweating.
Complications: CHF and pulmonary edema can develop rapidly and lead to death.
Hyperthyroidism
S/S: Nervousness, irritability, emotional lability, tremor, excessive appetite, weight loss, smooth and moist skin, increased perspiration, heat intolerance, goitre, exophthalmos, tachycardia, widened pulse pressure.
Thyroiditis
Inflammation of the thyroid leading to hyperthyroidism.
Dx: Thyroid function tests - elevated T4, decreased TSH.
Tx: Varies, sometimes no therapy is warranted.
