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Endocrine Emergencies

Discover the key features, diagnosis, management, and complications of endocrine emergencies such as Diabetic Ketoacidosis (DKA), Hyperosmolar Hyperglycemic Nonketotic Syndrome (HONK), Addisonian Crisis, and Thyroid Storm. Learn about ketones, vital parameters like Na and K, osmolality calculations, and comprehensive management strategies. Dive into fluid, potassium, insulin, and bicarbonate therapy, recognizing indications and risks for each. Be prepared to address potentially life-threatening conditions efficiently through this informative guide.

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Endocrine Emergencies

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  1. EndocrineEmergencies

  2. Name a Few… • DKA • HONK (HHOS) • Addisonian crisis • Thyroid storm • Myxoedemic coma

  3. What’s the Diagnosis? • 83yr woman with 3/7 histroy of malaise and polyuria. PMH type I DM and HTN • HR 100, BP 100/60, GCS 14, SaO2 100% on high flow O2 • Na 125 • K 6.0 • Cl 81 • HCO3 7 • Ur 25 • Cr 262 • Glu 54.5 • Osmolality 337

  4. DKA • Definition • BSL increased • Ketones present • Anion gap >10 • HCO3 <15 • pH <7.3 • Mortality 5-15% (less in children) • Bewareif pregnant: 30-50% mortality

  5. All About Ketones • Beta-hydroxybutyrate • Detected by Medisense blood test • Higher in alcoholic ketoacidosis than in DKA • Acetoacetate • >6x the levels of above AFTER conversion (ie. May initially be negative) • measured by Ketostix urine test • Acetone • Detected on Acetest • Responsible for ketotic breath • How do ketones impact on management? • Endpoint = ketones cleared, normal anion gap

  6. Other Vital Stuff • VBG Anion gap metabolic acidosis Maybe metabolic alkalosis (vomiting), resp alkalosis (hyperventilation) • BSLHow does BSL impact on management? Aim decr no more than 5/hr • Na…How do I calculate corrected Na???? Average deficit 5-10mmol/kg Na + ( (Glu – 5.5) / 3 )So if Na is 128 and Glu is 65 – what is real Na? • How does Na impact on management? • K… How do I correct K for pH???? Average deficit 3-5mmol/kg Decr pH by 0.1 = Incr K by 0.5So if pH is 7 and K is 5.7 – what is real K? • How does K impact on management? • Osmolality… How do I calculate osmolality? Average body H20 deficit 100ml/kg Do I even have to? Can’t I just measure it?? (ie. 10% dehydration) (2 x Na) + Glucose + Urea • How does osmolality impact on management? • Aim decr by no more than 1-2/hr • Any other investigations? • ?precipitant; ?ARF; ?level of long-term control

  7. Let’s look at that gas again… • Na 125 • K 6.0 • Cl 81 • HCO3 7 • Ur 25 • Cr 262 • Glu 54.5 • Osmolality 337

  8. Management of DKA • It’s bloody confusing and hard to remember • Split into… 1) IV fluids 2) Potassium 3) Insulin 4) NaHCO3

  9. Fluids • Adult Child 1L stat10-20ml/kg bolus  rpt until haemodynamically stable 1L over 1hr Replace deficit over 48hrs  1L over 2hrs  1L over 4hrs Deficit = %dehydration x weight x 10  1L over 10hrs Use N saline Use 0.45% saline Use 0.45% saline and correct over 72hrs if Na >150 / Osm >320 if Na >150 / Osm >320 Watch: Na, osmolality, BSL Change to 0.45% saline + 5% dexwhen BSL <15 and also if….. BSL decreasing too fast (ie. >5/hr) BSL <10 but ketones ongoing

  10. Potassium • How do you correct for pH again? • Only add K in 2nd hour / once UO / K <5 • Adult • K 4-5 = 10mmol/hr • K 3-4 = 30mmol/hr • K <3 = 40mmol/hr • Child • Add 40mmol to 1L bag

  11. Insulin • Start after 1hr of fluids if K >3.4 (otherwise replace K first) • Do you give a stat dose of actrapid? • Actrapid infusion • 0.1iu/kg/hr (max 6iu/hr) • Decrease to 0.05iu/kg hr if…. • BSL <12 (stop for 15mins if still too low despite this) • Aim for BSL decrease of no more than 5/hr • K <3

  12. NaHCO3 • What are the indications? • pH <7 • HCO3 <5 • Life threatening hyperkalaemia • Coma • Haemodynamic compromise unresponsive to IV fluids • What is the dose? • 0.5 – 2mmol/kg over 1-2hrs • What is the endpoint? • pH >7.1 • HCO3 >10 • What are the risks? • Worsened intracellular acidosis, hypokalaemia, hypernatraemia, osmolar shifts and cerebral oedema, volume overload

  13. Cerebral oedema • 70% mortality; 10% have ongoing neuro deficit; more common in children • Onset 4-12hrs after starting trt • What are the symptoms? • Headache, decr LOC, decr HR, incr BP, pupil changes, seizure, urinary incontinence • How do you treat it? • Mannitol 0.5-1g/kg • 3% saline 5-10ml/kg over 30mins • Half maintenance fluids

  14. Hyperglycaemic Hyperosmolar State

  15. What’s the diagnosis (bearing in mind this is an endocrine talk)? • An 85 year old man is brought to your Emergency Department fitting. His family say that he has been lethargic and weak for the last two weeks. He has a PMH of polymyalgia rheumatica. These are his initial biochemistry results. • Na 99 mmol/L • K 5.9 mmol/L • Cl 68 mmol/L • BSL 2.2mmol/L • HCO3 - 21 mmol/L • Urea 10.1 mmol/L • Cr 180 umol/L • pH 7.1 • Anion gap normal • pCO2 31 mmHg • pO2 149.5 mmHg • BE 2.4 • HCO3 17.6 mmol/L

  16. Addisonian Crisis • Back to Part One’s!! • Effects of cortisol • Incr BSL (gluconeogenesis, lipolysis, decr ketogenesis, decr insulin release) • Effects of aldosterone • Incr Na (incr reabsorption) • Decr K (incr excretion in DCT) • Alkalosis (incr H excretion) • So…. what changes may be seen on bloods in view of the above? • Dehydration – fluid resistant hypotension • Decr osmolality • Decr BSL • Decr Na, Cl • Incr K • Non-anion gap metabolic acidosis • If 2Y hypoadrenalism patient euvolaemic with lower K, as aldosterone is still working

  17. Recognising Addisonian Crisis • Who gets it? • 1Y • Long-term steroids stopped abruptly • Adrenal haemorrhage (neonates, anticoagulated folk, sepsis (name the syndrome), trauma) • Addison’s disease • Prior surgical removal • Adrenal destruction due to other cause: infection (eg. TB, HIV, CMV), thrombosis, metastatic Ca • 2Y • Head trauma • Meningitis • In pregnancy (name the syndrome). • Pituiary failure • How do they present? • Hypotension, lethargy, weight loss, weakness, N+V, abdo pain, diarrhoea • Ie. Non-specifically unwell and not responding to conventional treatment plus characteristic electrolyte changes

  18. Management • Investigation • Name the investigation • Management • IV fluids ++++ (vasopressors may be needed) • Dextrose • Treat K if needed • Dexamethasone 10mg IV stat (give initially as doesn’t interfere with investigations) • …then hydrocortisone 250mg IV stat

  19. What’s the diagnosis? • 17yr old female presents feeling anxious, unwell, tremulous, hyperventilating, looking flushed. Recent history of abdominal pain and diarrhoea. • HR 130, T 38, BP 140/87, RR 24 • On examination: gallop rhythm, bibasal crepitations, abdomen SNT • pH 7.8 • PCO2 15 mmHg • PO2 192 mmHg (75-100)

  20. Thyroid Calamities • Back to Part One’s again! • Effect of T3+4 • Incr metabolism • Incr GI motility • Incr glucose absorption • Incr sensitivity to epinephrine and norepinephrine, increased beta-receptors

  21. Thyroid Storm • Clinical diagnosis – labs don’t differentiate • Mortality 10% treated, 90% untreated with death due to CV collapse • Who gets it? • Undiagnosed Graves • Meds – XS thyroxine / withdrawal from anti-thyroid drugs / iodine or contrast • Stressor – MI, DKA, OT

  22. Recognising Thyroid Storm • Diagnostic criteria • Fever >37.8 • Incr HR out of proportion to fever (ie. >120) • CNS disturbance (eg. Altered LOC, seizures) • Other • AP, N+V, diarrhoea, high output CCF (wide pulse pressure, S3 gallop rhythm), HTN, dehydration, sweating • Investigations – non-specific

  23. Management • A + B • Give O2 as consumption increased • C • IV fluids containing dextrose • Cardioversion better than drugs for arrhythmias • Treat cause • Definitive treatment • Esmolol 250-500mcg/kg bolus  infusion (safe as short half life; titratable; blocks cardiac and peripheral effects and slows conversion of T3 to T4) • If less severe can use PO propanolol • Hydrocortisone 100mg IV (slows conversion of T3 to T4 and decreases hormone release) • Propylthiouracil / methimazole / iodide • Supportive care • Ongoing fluids, monitor electrolytes and BSL, treat fever

  24. What’s the Diagnosis? (This was an actual patient I saw last week) • 58yr old man with non-specific malaise • PMH: hyperthyroidism treated with radioactive iodine; known to be non-compliant with treatment • OE: normal observations; mild oedema around eyes; examination otherwise unremarkable

  25. Myxoedema Coma • Who’s ever seen one??? • Mortality 50%; same triggers as thryoid storm • Symptoms • A: hoarseness, glottic oedema • B: decr RR • C: decr BP, CCF • D: decr LOC, hypothermia without shivering, seizures • E: hypoglycaemia, paralytic ileus • Management • ABC, treat cause • T3 has rapid effect, T4 has smoother improvement, give hydrocortisone • Monitor electrolytes esp Na and titrate fluids accordingly • Rewarming

  26. Anything else you want to talk about…? • Hyponatraemia? • Hypernatraemia? • Metabolic acidosis? • Sodium bicarb use?

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