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Endocrine Emergencies Compiled
Endocrine Emergencies Compiled
OUTLINE
• DEFINITION
• PATHOPHYSIOLOGY
• CAUSES
• COMPLICATIONS
• MANAGEMENT
DIABETIC
KETOACIDOSIS
NURUL NAJIHA BINTI ZAINUDIN
012014100095
HYPERGLYCEMIA
>11MMOL/L
More common in
Diabetes mellitus type
1
DKA
KETOSIS
KETONEMIA
ACIDOSIS
>3MMOL/L
KETONURIA >2+
CAUSES OF DKA
• Non-compliance to insulin
• Infections
• Stroke, MI
• Pancreatitis
• Trauma
• Alcohol intake/ drug abuse
• Medications
CLINICAL FEATURES
• Polydipsia
• Polyphagia
• Weight loss
• Abdominal pain
• Vomiting
• Leg cramp
• Visual disturbances
• Shortness of breath (Kussmaul breathing)
• Fruity smelling breath
• Confusion, drowsiness, coma
Sign of dehydration
- Sunken eyes
- Dry lips
- Coated tongue
- Tachycardia
- Tachypneoic
- CRT >2s
- Hypotension
INVESTIGATIONS
Full blood count Increase WBC counts
Renal profile Elevated urea & creatinine
Hyponatremia, hypokalemia
Blood glucose level >11mmol/L
Arterial blood gas pH <7.3
HCO3 <15mmol/L
Blood ketone >3mmol/L
Urine ketone >2+
Blood culture, C-reactive protein Infection screening
Chest x-ray Sign of infection
ECG
Severity of DKA:
a) Mild (venous pH <7.3, bicarbonate <15)
b) Moderate (venous pH <7.2, bicarbonate <10)
c) Severe (venous pH <7.1, bicarbonate <5)
TREATMENT
a) Correct hypovolemia/dehydration
- Average 6-8L may need to be given for first 24hr
- Normal saline 0.9%
- 1L in 1 hr
- 1L in 2 hr
- 1L in 4 hr
- 1L in 6 hr
- 1L in 8 hr
- Monitor patient closely and look out for fluid
overload or underhydration
b) Insulin therapy
- Continuous intravenous insulin infusion is
treatment of choice. Soluble insulin is diluted in
0.9% saline at a concentration of 1U/ml
- Give IV bolus 10U soluble insulin followed by
6U/hr by infusion pump
- Blood glucose should be monitored hourly
c) Potassium replacement
- Administration of potassium should begin:
- When ECG shows no evidence of hyperkalemia
- When ample urine output is demonstrated
- When plasma K is <5mmol/L
- Add 1g KCL in each 0.5litre of fluid initially
- Adjust according to serum potassium level:
Plasma potassium Potassium added
<3 40
3-4 30
4-5 20
>5 or renal failure none
SHAMALA ARUMUGAM
012014100176
Definition
• Known as addisons disease
• Life threatening condition due to insufficient
cortisol production
• Causes
- Autoimmune disease
- Removal or destruction of adrenal gland
- Infection
- tumours
Presenting history
• Non specific weakness
• Fatigue
• Weight loss
• GI upset (nausea, vomitting,
abdominal pain, diarrhea)
• Altered mental status
• Confusion
• Coma and lethargy
Clinical features
• Dehydration • Look for persistent
hypotension and
• Lethargy orthostatic
• Altered mental hypotension
status • Evidence of sepsos
• Cushingoid facies or trauma
• Hyperpigmentation
in buccal mucosa
Precipitating factors
• Stress
• Fever
• Recent surgery
• MI
• Trauma
• Drug history of long term steroid use
Investigation
• Haematological
- Full blood count
- renal profile
- ABG
- Plasma cortisol and ACTH
- Chest Xray
- ECG
- BLOOD CULTURE AND URINALYSIS
MANAGEMENT
• 1. Supportive measures
- Management in critical care
- Monitor ( ECG, Pulse oximetry, vital signs)
- 2 large bore IV access
- Secure airway, give supplemental oxygen & fluid administration
(0.9% NS)
2. Drug Therapy
- IV Dextrose 50% 40ml ( correct hypoglycaemia)
- Glucocorticoid replacement
- IV NaHCO3 (50mmol/L over 1 to 2 hrs) monitor acid base with
ABG
- TREAT PRECIPITATING CAUSE
CUSHING SYNDROME
CUSHING SYNDROME
• caused by high blood levels of cortisol
• Cushings disease is Cushings syndrome that results
from excess pituitary production of ACTH, usually
secondary to a pituitary adenoma
AETIOLOGY
• Excess secretion of cortisol by the adrenal cortex can be
ACTH dependent or ACTH independent
• ACTH dependent hyperfunction may result from excess
secretion by the pituitary gland, ectopic secretion from
neoplasm
• ACTH independent hyperfunction usually results from
therapeutic administration of corticosteroids or from
adrenal neoplasms
• Be sure to rule out other conditions associated with
hypercortisolism such as pregnancy, depression, alcohol
dependence, poorly controlled diabetes mellitus
SIGN
• Moon facies with plethoric appearance,
• Truncal obesity with prominent supraclavicular
• Dorsal fat pads (buffalo humps)
• Muscle wasting and weakness
• Skin appears thin, poor wound healing, and
purple abdominal striae
• Females with adrenal tumours can also come
with hypertrichosis, temporal balding, hirsutism
and menstrual irregularities
INVESTIGATIONS
• Dexamethasone suppression test: Low dose
dexamethasone test administration of 0.5mg
dexamethasone 6 hourly for 48 hours
(N: <50nmol/L)
• Urinary Free Cortisol (UFC) level
• Serum ACTH level (N: <4pmol/L)
• Pituitary imaging using MRI
with gadolinium
TREATMENT