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Endocrine Emergency

Endocrine Emergency. Chatlert Pongchaiyakul MD. - Hypoglycemia - Diabetic ketoacidosis - Hyperosmolar non - ketotic coma - Focal hyperglycemic seizure. - Thyroid Crisis - Myxedema Coma - Adrenal crisis - Hypercalcemia - Acute hypocalcemia. Hypoglycemia.

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Endocrine Emergency

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  1. Endocrine Emergency Chatlert Pongchaiyakul MD.

  2. - Hypoglycemia - Diabetic ketoacidosis - Hyperosmolar non - ketotic coma - Focal hyperglycemic seizure

  3. - Thyroid Crisis - Myxedema Coma - Adrenal crisis - Hypercalcemia - Acute hypocalcemia

  4. Hypoglycemia ระดับ Plasma glucose ต่ำกว่า 50 mg/dl “Whipple’s triad” - low plasma glucose - Neuroglycopenia - Corrected by glucose

  5. Classification • Fasting hypoglycemia - underproduction - overutilization • Post prandial hypoglycemia

  6. Underproduction of glucose • Hormone deficiency • Enzyme defect • Substrate deficiency • Acquired liver disease • Drug : alcohol, propanolol, salicylate,quinine etc.

  7. Overutilization of glucose Hyperinsulinism • Insulinoma • Exogenous insulin • Sulfonylurea Appropriate insulin • Extrapancreatic tumor • Carnitine deficiency

  8. Treatment • Good conscious • Oral intake • Correct cause of hypoglycemia • Monitor plasma glucose

  9. Unconscious • 50% glucose 50 ml IV. ตามด้วย 10% Dextrose intravenous drip 125 - 250 ml/hr. • Glucagon 1 mg IM

  10. Diabetic Emergency • DKA • HONC • Focal hyperglycemia seizure

  11. DKA • Kussmaul’s breathing • Polyuria, polydipsia, polyphagia • Alteration of conscious • Other : dehydration, nausea, abdominal pain etc.

  12. Diagnosis • Plasma glucose > 300-350 mg/dl • Wide anion gap acidosis • Serum Ketone + ve • not necessary

  13. HONC • Neurological Sign & Symptoms • Severe Dehydration • Evidence of infection

  14. Diagnosis - Plasma glucose > 600 mg/dl - Effective Osmolarity > 320 mOsm/lit - Serum Osmolarity > 340 mOsm/lit - PH > 7.30 - HCO3 > 15 mEq/lit - Prerenal azotemia

  15. Treatment • Initial lab CBC, UA, BS, BUN, Cr, Electrolyte, ketone, ABG. Calculated osmolarity Septic work up

  16. Fluid 0.9% Na Cl 1000 - 1500 CC. ในชั่วโมงแรก1000 CC.ในชั่วโมงที่ 2500 CC.ในชั่วโมงที่ 3 250 CC.ในชั่วโมงที่ 4 และต่อไป- ถ้า Na > 150 0.45% Na Cl- ผู้ป่วยสูงอายุ CVP

  17. Insulin • Short actig (IV / IM) - 10 u IV. - 10 u IV drip / hr. (ผสมใน Na Cl) • Monitor BS q 1 hr. Electrolyte q 2-4 hr, osmolarity, Anion gap

  18. BS < 300 เปลี่ยน 5%DW หรือ 5% DN/2 125-250 ml/hr. Insulin 10-12 u Sc. q 4 hr. หรือ IV.drip low dose (2 u/hr) NaHCO3 - pH < 6.9, 7.0 - Cardiovascular instability : 100 mEq IV drip in 1 hr.

  19. Potassium If serum K 3 mEq ให้ KCl 30 mEq/hr. serum K 3-4 mEq ให้ KCl 20 mEq/hr. serum K 4-5 mEq ให้ KCl 15 mEq/hr. serum K 5-6 mEq ให้ KCl 10 mEq/hr. serum K 6 mEq ไม่ให้ KCl idividual adjustment with monitoring

  20. THYROID STORM • Underlying hyperthyroidism • Without treatment, inadequate treatment • Precipitating cause

  21. Precipitating Cause 1. Inappropriate treatment 2. Surgery 3. Infection 4. Injury 5. Radioactive iodine

  22. Principle 1. Supportive treatment 2. Specific treatment 3. Correct prcipitating Cause

  23. Specific treatment • Inhibit thyroid hormone synthesis • Inhibit thyroid hormone secretion • Inhibit thyroid hormone at peripheral tissue

  24. PTU • Inh. Synthesis, secretion, periphecal conversion (T4 T3) • 900 - 1200 mg/d x 1-2 d. (4 x 4, 4 x 6, 2x12) • ฏ dose 600 mg/dl • 3 x 3 (450 mg/d) x 3 wk Definite treatment

  25. Iodine • Lugol’s solution (10 mg/drop) 10 drops q 8 hr. • SSKI (50 mg/drop) 4 drops q 8 hr.

  26. Correct precipitating cause • Infection • Surgery • Advice antithyroid drug

  27. Controversy • - blocker : 40 mg q 4 - 6 hr. - oral (propanolol) 1 mg/min IV drip Corticosteroid : Dexamethasone 2 mg IV q 6 hr.

  28. Practical point 1. ในกรณีไม่แน่ใจว่า Thyroid storm หรือ severe hyperthyroidism ให้รักษาแบบ thyroid strom ไว้ก่อน 2. การให้ propanolol ยัง Controversy 3. ถ้าจะให้ corticosteroid ต้องแน่ใจว่า สามารถควบคุมการติดเชื้อได้ดี

  29. 4. ถ้าเกิด thyroid strom หลังผ่าตัดให้ พิจารณา PTU / MMI rectal suppository, contrast media injection 5. ต้องให้ Lugol’s solution หรือ SSKI หลังจากให้ PTU ไปแล้ว 1 ชั่วโมง 6. ไม่ต้องรอผล thyroid function test

  30. Myxedema Coma • Hypothyroidisim • Thyroidectomy scar • History of I 131 treatment

  31. Precipitating cause 1. Infection 2. Sedative drug 3. การได้รับน้ำเกลือที่เป็น hypotonicity 4. Cold temperature

  32. Symptoms & signs • Sign of hypothyroidism • Hypothermia • Bradycardia • Hypoventilation • Hyponatremia • Coma

  33. Investigation • Routine lab • TFT, Electrolyte • EKG - low voltage - Flattening or inverted T-Waves

  34. Principle 1. Supportive treatment 2. Specific treatment 3. Correct precipitating Cause

  35. Supportive treatment • Body temperature • Correct hypoventilation • Correct hyponatremia • Coma care • Hydrocortisone 300 mg IV in 24 hr.

  36. Specific treatment • Eltroxin - 400 - 500 ug IV drip slow Day 1 or 1000 ug NG - tube - Onset 6 hr. - ฏ dose 100 ug/d ในวันถัดไป

  37. Correct precipitating cause • Evidence of infection and treatment • Stop sedative drug • Advice Medication

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