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Endocrine Emergencies

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

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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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