Endocrine Emergency casesABDALLA ALZAABIEM (FRCP) R1

Learning objectives To understand how the common

Endocrine Emergencies present and how to initially treat them in the

emergency department

Case 1 50 M CC: confused and ataxic with slurred speech. PMH: none Med: none Exam: Appear drunk. mildly tremulous, sweating. mildly tachycardic and hypertensive.

Alcohol breath test Negative His fingerpick blood glucose reading was 1.6 mmol/L.

Is the presentation in keeping with hypoglycemia?

YES He has a combination of autonomic symptoms (e.g. sweating, tachycardia, tremor) and neuroglycopenic symptoms (e.g. confusion, ataxia, dysarthria).

What is Whipple’s triad? Whipple’s triad confirms the diagnosis of clinically significant hypoglycemia. It consists of:

The presence of symptoms consistent with hypoglycemia Low serum glucose level Resolution of the symptoms and signs of hypoglycemia with the administration of glucose

What are the causes of hypoglycemia?

What is the emergency treatment of hypoglycemia?

In the awake, cooperative patient:

Oral Glucose

In the uncooperative or unconscious patient:

No IV access give glucagon 1mg IM/SC

IV access give 50 mL 50% glucose

Following the initial management of his hypoglycemia, the patient became more lucid. Meanwhile, his wife arrive and tell you that she found her diabetic medication bottle empty

What is the antidote for overdose?

Octreotide 50–100 mcg IV or SC

Learning points Case 1: Always check blood glucose level in patient with

Altered Mental Status The antidote for sulfonylurea overdose is Octreotide

Spot Diagnosis? Acanthosis nigricans

Case 2 20 M HPI: abdominal pain, nausea, and vomiting with increasing polyuria, polydipsia, and drowsiness since the previous day. He was diagnosed with type 1 diabetes 2 years previously. He mentions that he ran out of insulin 2 days ago.

Exam: BP 106/67 mmHg, HR123, RR32 , temperature 37.1°C (98.8°F). drowsy. deep and rapid respiration with acetone odor and mild generalised abdominal tenderness without guarding and rebound tenderness.

Labs: BG (450 mg/dL), arterial pH 7.24, pCO2 25 mmHg, bicarbonate 12 mmol/l, WBC count 18.5 × 10^9/L , sodium 128 mmol/L , potassium 5.2 mmol/L , chloride 97 mmol/L , serum urea 11.4 mmol/L (32 mg/dL), creatinine 150.3 micromol/L (1.7 mg/dL), serum ketones strongly positive.

What is the diagnosis? Diabetes Ketoacidosis

D= Blood Glucose Level >250mg/dl (450) K= moderate degree of ketonemia and ketonuria (serum ketones strongly positive) A= Arterial PH <7.3, HCO3 level <15mEq/l. (arterial pH 7.24, bicarbonate 12 mmol/l)

What is the trigger for DKA in this case?

Incompliance with medication I= Infection I= Infarction/Ischemia I= Intrauterine pregnancy I= Interactions/Illegal (drugs) I= Idiopathic (newly diagnosed DM)

What is the pathophysiology of DKA?

Relative lack of insulin + stressors causes hyperglycemiaHyperglycemia-induced osmotic diuresis causes polyuria, dehydration, hypovolemia, electrolyte loss (K, Mg, Phos) Switch over to fat breakdown for energy source causes ketonemia (acidosis) Metabolic acidosis causes compensatory hyperventilation (Kussmaul respirations= deep rapid respiration)

What is the management of DKA?

Fluid Replacement NS bolus followed by 1/2NS when hemodynamically stable, then D5 1/2NS when glucose <300

Insulin Replacement insulin infusion at rate 0.1unit/kg/hr (5-10U/hr) aim for decrease glucose by 50mg/hr. Given until ketones cleared and

anion gab normalized

Potassium Replacement Serum K level; >5mmol/l no K, <5-3.3 add 20-30 mmol KCL in each litter of NS, <3.3 add 40mmol KCL in each L of NS

and no insulin until K >3.3

Treat precipitant

Learning Points Case 2 Volume resuscitation is most important

step in managing DKA Check potassium before giving Insulin !

Case 3 6 B CC: 5 days of vomiting. He was initially seen by his family doctor and treated for gastroenteritis. However, his vomiting has persisted and he is lethargic and no longer able to walk. He has no history of fevers, abdominal pain or diarrhoea.

PMH: none Med: none Exam: T36.4C, P 120/min, BP 95/60mmHg, R24/min and SpO2 99%RA. He is drowsy and generally weak with no focal neurological deficits, and is able to protect his own airway. He has dry mucus membranes and his eyes appear sunken though his capillary refill time is <2 seconds.

What is your immediate management priority?

Check the blood glucose

His fingerprick blood glucose is 1.9 mmol/L. He is immediately treated with 2mL/kg of 25% glucose IV.

Blood tests were taken on arrival. Of note are the following:

Sodium 117 mmol/L (135-145 mmol/L) Potassium 6.1 mmol/L (3-5 mmol/L) Urea 17.1 mmol/L (3-7 mmol/L) Creatine 111 umol/L (50-90 umol/L)

based on the laboratory data and the clinical information, what diagnosis must be suspected?

Acute adrenal insufficiency

• anorexia, vomiting, weakness, hypoglycemia, hypotension• dehydration, hyponatremia, hyperkalemia, pre-renal

impairement

What are the possible underlying causes of this

condition?

Describe the acute management of this condition?

1. ABCs

2. Treat shock if present

3. Correct hypoglycemia if present

4. Correct hyperkalemia if present

5. Give steroids

6. Give minerocorticoid if deficient

7. Treat precipitating causes

8. Refer to Endo for admission

Learning points case 3 Always check blood glucose level in patient with

Altered Mental Status

All that vomits is NOT gastroenteritis!

Skin hyperpigmentation in primary adrenal insufficiency

Case 4 24 F CC: fever, generalized abdominal and flank pain associated with severe nausea and vomiting, and dysuria for one day. She also had severe palpitations, poor concentration,anxiety, retro- bulbar pain, redness of eyes, painful eye movement and swelling around her eyelids.

PMHx: Graves hyperthyroidism Dx 9month ago Med: methimazole: but non-compliant for past 2M Sx: tremendous stress due to post graduate examination. examination: restless, dehydrated, Temp 39.7 (F103.5), P132/min(IR), BP 120/76mmHg. generalized abdominal tenderness, Her thyroid was bilaterally enlarged with bruit. Eye examination revealed bilateral exophthalmoses. ECG: Atrial Fibrillation

Is the presentation keeping with thyroid storm? YES

What are the precipitants in this case?UTI STRESS NON-Compliant

Do you know of Any Diagnostic tool to help you in diagnosing Thyroid Storm?

scoring system developed Burch and Wartofsky can help distinguish between thyrotoxicosis, impending thyroid storm, and frank thyroid storm A score of 45 or higher suggests thyroid storm, a score of 25-44 suggests impending storm, and a score

below 25 is unlikely to represent thyroid storm

Fever, generalized abdominal and flank pain associated with severe nausea and vomiting, and dysuria for one day. She also had severe palpitations, poor concentration,anxiety, retro- bulbar pain, redness of eyes, painful eye movement and swelling around her eyelids.

PMHx: Graves hyperthyroidism Dx 9month ago

Med: methimazole: but non-compliant for past 2M

Sx: tremendous stress due to post graduate examination.

examination:

restless, dehydrated, Temp 39.7 (103.5), P132/min, BP 120/76mmHg.

generalized abdominal tenderness,

Her thyroid was bilaterally

enlarged with bruit.

Eye examination revealed bilateral exophthalmoses.

ECG: Atrial fibrillation

What is the treatment for thyroid storm?

Learning points case 4 Treat peripheral

Prevent synthesis Prevent release

Pretibial myxedema

Sources Rosen’ Emergency medicine 8th edition Tintinalli Emergeny Medicine Life in the fast lane http://bestpractice.bmj.com/ High Yield emergency medicine