Metabolic Emergencies Lecture Powerpoint Flashcards
2 general causes of hypoglycemia
- excess endogenous or exogenous insulin intake
- Failure of organs which produce or mediate glucose metabolism (pancreas, liver)
General story of hypoglycemia (5)
- Delay in eating after insulin dosing
- malnutrition or inadequate food intake
- acute N/V after insulin dose
- increased physiologic stress (infection, injury, emotion, etc)
- excessive endogenous insulin release with oral agents in a patient with renal insufficiency
Glucose reference range
65-110 mg/dL
Glucose drop to 30-50mg/dL causes ____ release resulting in irritability, hunger, trembling, diaphoresis, tachycardia
Catecholamine
Glucose drop to <30mg/dL causes ___ effects
Neuroglycopenic (focal neurologic deficits, headaches, confusion, visual disturbances, seizure like activity, hypothermia)
Hypoglycemia diagnosis (4)
- good history
- finger stick (can be inaccurate in severely low)
- serum glucose level
- rule out other causes
Hypoglycemia treatment options (4)
- Glucose IV D50 (dextrose)
- Oral glucose gel/tabs
- food if conscious and capable of swallowing
- glucagon 1mg IM, IV, or SQ
Glucagon is released from the ___ cells of the pancreas, insulin from the ___, and somatostatin from the ___ cells
Alpha, Beta, delta
Diabetic ketoacidosis (DKA) definition
Most common life threatening complication of diabetes, more common with DM I but can occur with DM II, caused by profound deficiency of insulin resulting in hyperglycemia but no corrective actions to get it into cells, combined with hormones such as glucagon, cortisol, epi, etc worsens, leads to triglyceride breakdown for energy and production of ketones (acidosis)
Common presentation of a patient with new onset type I diabetes
Diabetic ketoacidosis
Clinical presentation of Diabetic ketoacidosis (DKA) (6)
- acute headache
- polyuria and polydipsia
- acute weakness/lethargy
- Kussmaul respiration
- dehydration
- acidosis (fruity breath)
Diabetic ketoacidosis Diagnosis (6)
- history and symptoms
- blood glucose >250mg/dL
- urine ketones
- ABG (serum bicarb <15)
- hyperkalemia
- chemistry panel (glucose electrolytes and renal function) and serum ketones
The Anion gap
Measure of the difference between serum Na+ and (Cl- + HCO3- (bicarb)), Normal 8 + or - 4mmol/L, >12mmol/L is elevated and has its own subset of etiologics that are causing said metabolic acidosis (MUDPILERS acronym)
MUDPILERS acronym for the common cayses of metabolic acidosis with increased anion gap
- Methanol
- Uremia
- Diabetic/alcohol/starvation ketosis
- Paraldehyde
- Iron
- Lactic acidosis
- Ethylene glycol
- Rhabdo
- Salicylates
Diabetic ketoacidosis treatment options (5)
- IV fluids first (500 mL/hr)(once you start insulin, the glucose will go into the cells and water will follow resulting in dehydration)
- Insulin 10U bolus then 5U/hr 1 hour after IVF, follow blood sugar and lower gradually 100/hr
- K+ replacement, if urinating dose depending on T waves, if anuric and peaked T waves wait for labs to determine
- Start Dextrose once blood glucose is 200-250mg/dL
- Switch to SQ insulin at least 1/2 hour before stopping insulin drip
Too rapid of a drop in blood glucose in correcting diabetic ketoacidosis can result in….
….cerebral edema
Hyperosmolar hyperglycemic state (HHS) definition and average level of glucose elevation
Insidious onset (days to weeks) ketone free that sees adequate insulin activity but decreased cell response (type 2 DM in most cases) and hence an absence of lipolysis and ketogenesis (low or absent serum/urine ketones), can have precipitating infection or stressor, has severely elevated glucose levels often >600mg/dL (wayyy higher than DKA typically)
Hyperosmolar hyperglycmeic state (HHS) clinical presentation (4)
- typically >60
- chronic care facility
- change or addition of new med
- recent or current infection***
Hyperosmolar hyperglycemic state (HHS) signs and symptoms (4)
- significant dehydration
- depressed mental status
- focal neurologic abnormalities
- Kussmaul respiration and nausea/vomiting usually NOT present
Hyperosmolar hyperglycemic state (HHS) treatment options (3)
- Admit to ICU
- IV fluids judiciously (congestive heart failure patients often comorbid)
- IV insulin or DM meds to increase insulin sensitivity
Alcoholic ketoacidosis (AKA) definition
Seen in chronically malnourished patients who consume large quantities of alcohol daily often after a recent binge, see high ketones and acidosis but low/normal glucose, similar to a starvation state (glycogen depletion and subsequent lipolysis with ketone production in liver), diagnosis supported by absence of history of diabetes, history of alcohol use, no evidence of glucose intolerance
Alcoholic Ketoacidosis Treatment options (3)
- Administration of IV dextrose can correct the acidosis
- thiamine 100mg IV or IM
- address alcohol abuse
Blood alcohol concentration (BAC) measurement
- 50mg/dL (.05%) loss of restraint, emotional
- 80mg/dL (.08%) legal limit for intoxication in PA
- 100mg/dL (.1%) slurring speech and confusion
- 200mg/dL (.2%) very slurred speech and staggering
- 400mg/dL (.4%) comatose and incontinent
- 500mg/dL (.5%) possibly lethal suppression of breathing
Blood alcohol concentration (BAC) measurement
- 50mg/dL (.05%) loss of restraint, emotional
- 80mg/dL (.08%) legal limit for intoxication in PA
- 100mg/dL (.1%) slurring speech and confusion
- 200mg/dL (.2%) very slurred speech and staggering
- 400mg/dL (.4%) comatose and incontinent
- 500mg/dL (.5%) possibly lethal suppression of breathing
Alcohol intoxication/poisioning diagnosis
-Based on history and symptoms and clinical presentation -> NO specific BAC level
Lactic acidosis definition
Biproduct of anaerobic glucose metabolism characterized by elevated anion gap and serum lactate at least 4-5mmol/L and pH <7.35, seen in hypoxia or decreased tissue perfusion
Lactic acidosis diagnosis (4)
- hyperventilation to blow off CO2
- altered mental status
- high serum phosphate
- precipitating cause
Lactic acidosis treatment options (4)
- Treating the underlying cause
- empiric antibiotics if sepsis suspected
- high flow O2
- IV normal saline
Thyroid storm etiology (5)
- infection
- stopping antithyroid meds
- recent surgery
- trauma
- pregnancy
Thyroid storm clinical presentation (6)
- high fever often >104
- tachycardia
- delirium
- N/V and diarrhea
- agitation, tremor
- exopthalmos
Thyroid storm diagnostic labs (2)
- low TSH
- high free T4
Thyroid storm treatment options (4)
- propylthiouracil or methimazole
- propranolol
- hydrocortisione
- radioactive idione or surgery definitive treatment but delayed until euthyroid
Myxedema coma clinical presentation (5)
- hypothermia
- hypoventilation
- hypotension
- seizures and abnormal CNS signs including altered mental status
- often elderly women
Myxedema coma treatment options (5)
- levothyroxine synthroid IV and repeated daily
- hydrocortisone if adrenal insufficiency suspected
- blankets but no active warmers
- treat any possible underlying infection
- intubation if respiration too low
Adrenal insufficiency (addison’s disease or addisonian crisis) definition
Often precipitated by surgery, trauma, infection, or sudden withdrawal of exogenous adrenocortical hormone, etc
Adrenal insufficiency (addison’s disease or addisonian crisis) signs and symptoms (4)
- headache
- nausea/vomiting
- confusion or coma
- fever
Adrenal insufficiency (addison’s disease or addisonian crisis) lab findings (3)
- low cortisol level
- high eosinophil
- electrolyte abnormalities
The synthetic ACTH cosyntropin stimulation test
-Confirmatory diagnosis for adrenal insuficiency where serum cortisol level is checked at baseline then .25 synthetic ACTH cosyntropin is given parenterally, serum is then obtained at both 30 and 60 min after administered, should normally rise at elast 20mcg/dL and if not primary deficit exists in the adrenals
Adrenal insufficiency (addison’s disease or addisonian crisis) treatment options (2)
- Hydrocortisone or dexamethasone IV
- long term gluco and minaralocorticoid long term treatment
Calcium metabolism pathways
- Parathyroid glands sense low serum calcium and increase PTH secretion which causes mining out of the bones to increase calcium
- vit D converted in liver to form that increases increases absorption of dietary from the small intestine and kidneys to decrease excretion
Hypocalcemia etiologies (3)
- Decreased intake
- increased loss
- endocrine disease
Hypocalcemia signs and symptoms (3)
- mild often asymptomatic
- severe sees tetany, weakness, fatigue cramps, dyspnea and stridor
- chvostek sign and trousseau sign
Chvostek sign
Tap over facial nerve 2cm anterior to tragus of ear, depending on ca2+ levels see twitching of angle of mouth, or in more severe then nose, eye, facial muscles
Trousseau sign
Inflation of blood pressure cuff above systolic pressure causes localized ulnar and median nerve ischemia resulting in carpal spasm (contraction)
Hypocalcemia diagnostic labs (3)
- low Ca2+ <2mg/dL
- ABGs
- EKG prolongation of QT interval
Hypocalcemia treatment options (1)
-Calcium chloride or calcium gluconate
Hypercalcemia causes (3)
- increased intake or absorption
- endocrine disorders of parathyroids
- neoplastic disease
Hypercalcemia signs and symptoms (2)
- often asymptomatic up to levels of 12mg/dL
- CNs depression, stupor, weakness, constipation, abdominal pain
Hypercalcemia diagnostic labs (2)
- calcium >12mg/dL
- EKG prolonged PR interval
Hypercalcemia treatment options (3)
- IV normal saline
- furosemide
- bisphosphonates
