endocrine emergencies
DESCRIPTION
From Prof IkramTRANSCRIPT
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Endocrine Emergencies
Professor Ikram S IsmailProfessor Ikram S IsmailPhD (Wales) FRCP (Edin) FAMM FACE
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Endocrine Emergencies Diabetic Coma
Hypoglycaemia Diabetic Ketoacidosis Hyperosmolar nonketotic coma
Thyroid storm
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UnconsciousDiabetic
Normal
BelowNormal
Look for non-diabetic cause
HypoglycaemicComa
High
Hyperventilation?
Yes
No
pH Low?No
Yes
Look forother illness
Hyperosmolarity?
Yes No
DiabeticKetoacidosis
Plasma Ketones orUrine Ketones +++
Yes No
Consider LacticAcidosis
Other Acidoses
HyperosmolarNonketotic
Coma
Consider CVA, othercauses after checking
ketones
BloodGlucose?
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Diabetic Ketoacidosis Results from lack of insulin Occurs in people with type 1 diabetes.
Can also occur in type 2 DM in severe stress.
Medical emergency that needs urgent hospitalization
Accounts for approximately 5% mortality
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Causes of DKAA. Absolute Insulin Deficiency: Omission or reduction of
insulin Undiagnosed diabetes
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Causes of DKAB. Relative Insulin Deficiency:
(excess catabolic hormone secretion with fixed insulin dosage)
Acute illness: Infection Myocardial infarction Stroke Trauma Severe emotional disturbance
Endocrine Disorders Steroid therapy Adrenergic agonists Phaeochromocytoma Thyroid storm
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DKA: Pathophysiology
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DKA: Pathophysiology
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DKA - Symptoms Symptoms develop over several hours
Thirst, Polyuria Osmotic Diuresis
Fatigue Dehydration, protein loss
Weight lossProtein loss, catabolism, dehydration
Nausea, vomiting ?Ketosis, gastric stasis
Abdominal pain ?ileus, gastric stasis, K deficit
Muscle cramps ?K deficiency
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DKA - Signs
Dehydration Osmotic Diuresis, vomiting
Tachycardia Dehydration
Hypotension Dehydration, acidosis
Warm skinAcidosis (peripheral vasodilatation)
Hyperventilation Ketosis, acidosis
Coma, drowsiness Hyperosmolality
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DKA - Diagnosis
Diagnostic procedures Determine blood glucose level
and test for ketones Send blood to laboratory for
estimation of glucose, urea, electrolytes,arterial pH, pO2, pCO2, Hb, and WBC
Send for culture of blood, urine and lung secretions
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Blood Ketone TestingIndications Asymptomatic patients with glucose >
16.70 mM Symptomatic patients with possible DKA Monitoring in established DKA To assist in making decision on admission To assist in making decisions for intensive
medical therapy
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<0.6 Check clinical status
0.6 – 1.5 Retest glucose and ketones in 2-4hrs
>1.5 If concurrent stress and poor compliance - admit
>3.0 Established DKA
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DKA – InvestigationsHyperglycaemia, hyperketonaemia
Insulin deficiency
Decreased pH, PCO2, bicarbonate
Increased ketogenesis
Hyponatraemia Hyperglycaemia
Variable KInsulin deficiency, acidosis, urine loss
Raised WCC Hyperketonaemia
Raised haematocrit Dehydration
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DKA - DeficitsWater 5 to 8 liters
Sodium 400-700 mmol
Chloride 300-500 mmol
Potassium 300-1000 mmol
Calcium 100 mmol
Magnesium 50 mmol
Phosphate 50 mmol
Bicarbonate 350 to 400 mmol
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Treatment of ketoacidosis Initiation of treatment must be
immediate Treatment includes
Rehydration Insulin administration Electrolyte correction Stabilization of cardiovascular and
and renal function
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Treatment of ketoacidosis Fluids
Most urgent and first line treatment Rehydration alone will cause fall in glucose
Increase urine flow Allow perfusion
Saline given rapidly 1 L in 30min, then hourly for 3 hrs CVP monitoring in elderly/CVS disease
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Treatment of ketoacidosis Insulin
Aim to switch off gluconeogenesis, lipolysis, ketogenesis
Insulin regimens Intramuscular:
20 units stat, then 5U/hr Children: 0.25 U/kg stat, then 0.1 U/kg/hr
Intravenous infusion Adults: 6 U/hr Children 0.1 U/kg/hr
Once glucose fallen to below 15 mmol/L, replace saline with 10%Dextrose with 20-40 mmol K, reduce insulin to 3 U/hr
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Treatment of ketoacidosis Potassium
Hypokalemia most common cause of death Potassium will fall during therapy:
Move into cells resulting from insulin, correction of acidosis, and restoration of volume
Haemodilution Urinary loss
Begin with insulin treatment: 20 mmol/h
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Treatment of ketoacidosis
Hazards of acidosispH<7
Hazards of alkali therapy
Negative inotropismPeripheral vasodilatationCerebral depressionInsulin resistanceEnzyme depression
HypokalaemiaIncreased anaerobic glycolysisImpaired tissue oxygen deliveryParadoxical fall in CSF pHRebound alkalosisSodium overload
Acid-base
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Treatment of ketoacidosis Acid-base
Give 100 mmoL with KCl 200 mmol when pH < 7, repeat until pH 7
Symptomatic relief: 50 mmoL with KCl 10 mmol
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Treatment of ketoacidosis Clinical measures
Gastric stasis: NG suction in drowsy pts Infection:
Usual signs lacking Hyperglycaemia increases risk of sepsis Use broad spectrum antibiotics after cultures
Risk of thrombosis Prophylactic SC Heparin 5000 units q6-8hrly in the
unconscious, elderly, hyperosmolar Hypotension: use plasma expanders Clinical monitoring
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Complications of treatment ARDS
Sudden dyspnoea, hypoxaemia, diffuse pulmonary infiltrates
Younger pts, fatal Mechanisms:
Use of crystalloids Alveolar defect caused by acidosis snf hyperventilation
Cerebral oedema High mortality Use of hypotonic replacement fluids
Abdominal pain Can mimic acute abdomen
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Hyperosmolar Non-ketotic Hyperglycaemia
Accounts for 5-10% of hyperglycemic comas
Mortality 30-50%, usually from arterial or venous thrombosis
Occurs mainly in elderly persons with type 2 diabetes
When compared with DKA, it has: Higher mortality Higher hyperglycemia More severe dehydration
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HONK: Treatment Rehydration is the most important
treatment Is performed under close observation
of circulatory status
Insulin concentration is usually low Blood glucose will drop in parallel
with rehydration
Patients should be monitored in a special intensive care unit
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HypoglycaemiaHypoglycaemia
Defined as blood glucose below 3 mmol/l Some people with diabetes develop
hypoglycaemic symptoms even when BG > 3 mmol/l
Some persons with diabetes do not have symptoms even at very low BG Hypoglycaemic unawareness
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Causes of HypoglycaemiaCauses of Hypoglycaemia
Administration of too much insulin. Insufficient intake of carbohydrate. Delay or omission of a snack or main meal. Performing more exercise than usual. Overdosing of sulphonylureas. Over-indulgence in alcohol.
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Hypoglycaemia : Symptoms and SignsHypoglycaemia : Symptoms and Signs
Autonomic Neurologic Nonspecific
Sweating Diminished psychomotor skills
Headache
Tremor Irrational and aggressive behavior
Dizziness
Palpitations Confusion Generalized weakness
Hunger Altered
salivation
Convulsions Coma
Paraesthesia
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Hypoglycaemia : ClassificationHypoglycaemia : Classification Mild hypoglycaemia
Activation of the autonomic nervous system Symptoms: tremors, palpitations, sweating, hunger The patients are able to treat themselves
Severe hypoglycaemia Very low blood glucose level Symptoms : confusion, drowsiness, coma, seizure Help is needed from others or consciousness is lost Acute professional assistance may be needed
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Nocturnal HypoglycaemiaNocturnal Hypoglycaemia Usually occurs between 2 and 4 am Diagnosis through :
Symptoms in the night and next morning Blood glucose testing at the time of occurrence
Treatment Add a snack before bedtime Reduce dose of insulin Adjust timing of insulin injection Change the type of insulin
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Hypoglycaemia Caused by Sulphonylureas
Hypoglycaemia Caused by Sulphonylureas
More common with longer acting sulphonylureas Chlorpropamide Glibenclamide
Treatment with glucose Hospitalisation with severe
hypoglycaemia Alternative diabetic treatment
Shorter acting sulphonylureas Metformin
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Hypoglycaemic UnawarenessHypoglycaemic Unawareness
Low blood glucose without symptoms
Associated with Long duration of diabetes
Condition requires frequent blood glucose monitoring
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Treatment of Mild HypoglycaemiaTreatment of Mild Hypoglycaemia
Relieved by 1 glass of fruit juice or soft drink 3 heaped teaspoon of sugar, honey or 3-5 sweets Dextrose tablets of 5 g
Repeat if symptoms are not relieved after 5 to 10 minutes
If next meal not immediately due, take 30 g of complex carbohydrate i.e. an apple or a slice of bread after recovery
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Treatment of Severe HypoglycaemiaTreatment of Severe Hypoglycaemia Confirm diagnosis with a portable meter Administer 1 mg of glucagon intramuscularly for
adults and for children >25 kg (children < 25kg, give 0.5 mg or 0.02 mg/kg body weight)
If next meal not immediately available, give 30 g complex carbohydrate
If the patient does not recover consciousness within 5-10 minutes, admit to hospital
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Thyroid Storm Life threatening exacerbation of
hyperthyroid state with evidence of decompensation in one or more organ systems.
Incidence : 10% of patient hospitalized for thyrotoxicosis
Fatal if not treated Mortality 20-30%
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Pathophysiology:
Levels of thyroid hormones Rate of rise of thyroid hormone Development of tissue
intolerance Role of adrenergic activation
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PathophysiologyLevels of thyroid hormones Most older studies found no
difference in thyroid hormone levels
Newer studies measuring free hormone levels showed higher levels of free T4 in thyroid storm
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PathophysiologyRate of rise of thyroid hormone Related to the change in levels of
binding proteins noted in systemic illness and postoperatively
Production of T4 binding inhibitors resulting in decreased binding affinity of T4 and increase free T4 levels
Rapid release of T4 into the circulation could saturate binding capacity
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Pathophysiology Development of tissue intolerance
Homeostatic decompensation despite similar hormone levels.
Role of adrenergic activation Normal plasma levels of adrenaline
noted But T4 causes increased receptors in
some tissues Post receptor action to alter
responsiveness to catecholamine
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Clinical presentation All of usual features of thyrotoxicosis -
usually exaggerated and severe History of previous thyroid disease
partially treated or a history of symptoms suggestive of thyrotoxicosis
Fever typically present Sweating profuse initially, later dry
when become dehydrated Pulse pressure widened
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Atrial arrhythmias Nausea, vomiting, diarrhea Increase motor and psychic
restlessness confusion, delirium, agitation
Unusual presentation reported acute abdomen status epilepticus, coma stroke
Clinical presentation
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Clinical Presentation Occasionally few or no thyrotoxic
features GI, cardiovascular or neurologic features predominate
May be impossible to distinguish between severe hyperthyroidism with concurrent illness and thyroid storm.
Usually thyroid storm, the fever and tachycardia tends to be out of proportion to the illness
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Precipitating events Infection Surgery Radioactive iodine Withdrawal of anti-thyroid drugs Amiodarone, thyroid hormone ingestion DKA, CCF, Hypoglycemia PET, parturition Vigorous palpation of the thyroid gland
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Diagnosis
Temperature99 - 99.9 5100 -100.9 10101 - 101.9 15102 -102.9 20103 - 103.9 25> 104 30
Mainly clinical Diagnostic criteria to aid clinical
diagnosis Thermoregulatory Dysfunction
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Diagnosis Central Nervous system
Effects Absent 0
Mild (Agitation) 10
Moderate Delirium Psychosis Extreme lethargy
20
Severe Seizure Coma
30
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Diagnosis Gastrointestinal-hepatic
Dysfunction Absent 0
Moderate Diarrhea Nausea/vomiting Abdominal pain
10
Severe Unexplained jaundice
20
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Diagnosis Cardiovascular dysfunction
Tachycardia Congestive Cardiac Failure 99-109 5 Absent 0 110-119 10 Mild
Pedal edema5
120-129 15 Moderate Basal crepitations
10
130-139 20 Severe Pulmonary edema
15
>140 25 Atrial fibrillation
Absent 0 Present 10
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Diagnosis Precipitant history
Negative 0
Positive 10
Clinical Diagnostic CriteriaA score of 45 or more is highly suggestive of a stormA score of 25-44 is suggestive of impending stormA score below 25 is unlikely to represent storm
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Laboratory Criteria No lab criteria for a storm
Biochemical evidence of thyrotoxicosis i.e. T3, T4, TSH
Free T4 tends to be higher but no criteria as yet
Do not wait for lab confirmation If diagnosis not clear and no known history of
hyperthyroidism, 2 hour RAI uptake useful Other suggestive features include
hyperglycemia, leukocytosis, hypercalcemia, AST, LDH.
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Treatment Correct hyperthyroidism
Block synthesis of additional hormones Block release of thyroid hormones Inhibit peripheral conversion Direct measures to reduce levels of
hormones Definitive treatment
Normalizing homeostatic decompensation
Treat precipitating event
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Treatment Correct hyperthyroidism
Block synthesis of additional hormones PTU, carbimazole orally, NG. Block iodine incorporation within 1 hour PTU loading dose 600-1000 mg, then 200-250
mg q4hr Carbimazole 20 mg Q4H
Block release of thyroid hormones Inorganic iodine only after carbimazole. Orally
or nasogastric. Lugol’s iodine 30 drops daily Ipodate (Oragrafin) 1 g tds. Also inhibit T4
conversion Lithium only if allergic to iodine
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Treatment Inhibit peripheral conversion
PTU Ipodate blockers with MSA e.g. propanolol steroids
Direct measures to reduce levels of hormones Plasmapheresis, PD, exchange transfusion
Definitive treatment Radioiodine must be delayed 6 months as
iodine can inhibit uptake
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TreatmentNormalizing homeostatic
decompensation IV Fluids to rehydrate Glucose for calories and restore
glycogen storage Multivitamins Treatment of arrhythmias, CCF. Pressors/invasive monitoring if indicated Supplemental oxygen
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Treatment Treat hyperthermia
Central thermoregulation Paracetamol. Aspirin can displace T4 from binding proteins
Peripheral measures icepacks, cooling blanket
Glucocorticoids Relative adrenal insufficiency due to increased
degradation of cortisol Absolute adrenal insufficiency associated with
Graves Disease Inhibit T4 to T3 conversion
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Treatment Cardiac failure
CCF usual treatment Arrhythmias: most common AF Large doses of digoxin needed Significant risk of embolism: anticoagulate
if no contraindications Anti adrenergic agents
Propanolol result in dramatic improvement 20-40 mg Q6h
1 selective, esmolol (short acting during perioperative period).
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Treatment Treat precipitating event
Identify and treat aggressively Infections
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Treatment Response
Clinical response within 12-24 hours - defervesence, reduced pulse.
Full recovery in 7-8 days Mental status good marker for
recovery.