Endocrine emergencies

By Dr. Mohammed Al Ameen

Hypoglycemia

• <60mg/dl, <4mmol/L• Protection against hypoglycemia is

normally provided by cessation of insulin release and mobilization of counter-regulatory hormones

Causes

• Overdose of insulin or oral hypoglycaemic agents

• Alcohol-induced hypoglycaemia• Addison’s disease • Insulinomas. • Liver failure. • Extra-pancreatic tumors.• Pituitary insufficiency.

Signs and symptoms

• Signs and symptoms of hypoglycemia are caused by excessive secretion of epinephrine and CNS dysfunction

• sweating, nervousness, tremor, tachycardia, hunger, and neurologic symptoms ranging from bizarre behavior and confusion to seizures and coma.

• hypoglycemia unawareness.• Somogyi phenomenon

Investigations

• Blood glucose• LFT• Electrolytes• ECG• C-peptide

Management

• C A B• 50% dextrose in water (D50W) is administered

intravenously• Alcohol-thiamine• <8yrs-25% (D25W) or even 10% (D10W) dextrose• Glucagon 1mg • Discharge- cause for the episode and fully recovered

Diabetic Ketoacidosis

• An acute metabolic complication of diabetes characterized by• hyperglycemia• hyperketonemia• metabolic acidosis

Causes

• Infection• Infraction• Insufficient insulin

Symptoms and signs

• Signs of dehydration• GI symptoms• Kussmaul respiration, fruity breath • Neurological symptoms :altered level of conciousness

,confusion, coma and death – if not treated timely

Investigations

• Blood glucose• ABG• Serum ketones• Infective screen• Blood tests— urea and electrolytes, FBC, and

bicarbonate• ECG and cardiac monitoring

Treatment• A B C• Fluid management -resuscitation -replacement • Insuline 0.1 unit/kg/hour, ketones do not fall by at least 0.5

mmol/L/hour the infusion rate should be increased by 1 unit/hour• Change IV solution to D5W when glucose concentration is ≤300

mg/dL• Potassium replacement Over 5.5mmol/l Nil 3.5–5.5mmol/l 20 mmol/LBelow 3.5mmol/l 40–60 mmol/L (HDU support required)

• Sodium, Phosphorus & magnesium• Bicarbonates• Monitoring: Fluid balance should be monitored,

aiming for a urine output > 0.5 ml/kg/hr. Blood ketones and capillary glucose should be measured hourly . ABG every 2 hrs.

Hyperosmolar hyperglycemic nonketotic syndrome

• Pathophysiology: there is enough circulating insulin to prevent ketogenesis , and therefore acidosis

• Clinical features similar to DKA• Investigation: blood glucose >30mmol/l, serum

osmolality• Management: similar to DKA

Acute adrenocortical insufficiency

• Precipitants of an adrenal crisis include: Infection.Trauma.Myocardial infarction.Stroke. Asthma.Hypothermia. Alcohol.• Exogenous steroid withdrawal/reduction.

Clinical features

• Onset is usually insidious with features including weight loss, lethargy, weakness, vague abdominal pain, nausea

• Adrenal crisis the patient can be profoundly shocked (tachycardic, hypotensive, vasoconstricted,oligouric) and hypoglycaemic

Investigation

Serum cortisol and plasma ACTHRFT:Hyponatraemia. Hyperkalaemia. Elevated urea and creatinine.Blood glucose: Hypoglycaemia.ABG: Metabolic acidosis.To identify the precipitant : ECG, CT, CBC, blood culture, CXR, urine routine .

Treatment

• A B C• Hydrocortisone 100 mg IV should be given as soon as

an adrenal crisis is suspected.• Fluid resuscitation• Patients should be monitored for hypoglycemia.• Treat the precipitant

Phaeochromocytoma

• functional tumors that arise from chromaffin cells in the adrenal medulla

• Catecholamines α –receptors and β -receptors

Clinical features

• Hypertension.• Palpitations.• Sweating.• Pallor.• Headache.• Anxiety.• Pulmonary oedema.• Nausea and vomiting.• Altered level of consciousness (hypertensive

encephalopathy)

Diagnosis

• 24-hour urinary free catecholamines level• CT/MRI

Treatment

• Phenoxybenzamine ( α -blocker) is the drug of choice.

• Propranolol

Thyroid storm

Precipitating factors of a thyroid storm

• Infection• Non-thyroidal trauma or surgery• Parturition, pre-eclampsia• Major acute medical conditions,

e.g.myocardial infarction, DKA, HONK,hypoglycaemia.

• Radioiodine or high-doses of iodine-containingcompounds, e.g. contrast media, amiodarone.• Discontinuation of anti-thyroid medication.• Thyroid hormone overdose• Thyroid injury (infarction of an adenoma, neck

trauma)

Clinical Feature

• Cardiovascular — severe tachycardia, atrial fibrillation, congestive heart failure, hypertension.

• Neurological — agitation, confusion, delirium, coma.• Gastrointestinal dysfunction — vomiting, diarrhoea,

acute abdomen.• Fever.

Investigation

• Bloods — renal function, glucose, calcium, FBC, thyroid function tests.

• Infective screen• ECG

Treatment

• Inhibition of thyroid hormone synthesis and release - propylthiouracil and carbimazole

- Iodide• Inhibition of peripheral effects of thyroid hormone

-propranolol 80 mg PO - hydrocortisone 100 mg IV or

dexamethasone 4 mg PO• Treat underlying cause• Supportive management

Myxoedema coma

• Myxoedema coma is a rare condition typically found in elderly patients with undiagnosed or undertreated hypothyroidism.

• Precipitants : infections or infractions • Clinical features :- Altered mental state ranging from

poor cognitive function to coma. -Hypothermia or the absence of fever despite severe infection• Management – Thyroid profile, Thyroid hormones,

Hydrocortisone, Rx precipitant

Thank you