endocrine emergencies resident rounds may 22, 2003 rob hall pgy3
TRANSCRIPT
Endocrine EmergenciesEndocrine Emergencies
Resident Rounds
May 22, 2003
Rob Hall PGY3
OutlineOutline
D K AH O N K S
H yp o g lyce m ia
A K A(fo r co m p a riso n)
D ia b e tic R e la ted
T h yro id A d ren a l
N o n -d ia b e tic
E n d oc rin e E m e rg en c ies
CaseCase
16yo female, DM1 Drinking, ecstacy at a
rave, no insulin Confused, dry,
borderline hypotension, tachy
Chemstrip 25 Urine gluc/ketone+ve Fruity breath
Na 129 K+ 5.1 HCO3 8 pH 6.95 PC02 20 Mg low P04 low
What is your approach to DKA?What is your approach to DKA?
Resuscitate the patient: ABCs Assess the severity of the DKA: physical exam,
dehydration, lytes, ABG Correct the metabolic derrangements:
hyperglycemia, acidosis, ketosis, dehydration Look for precipitant………..
– Lack of insulin: non-compliant, new dx– Physiologic stress: infection, pregnancy, ischemia,
drugs, alcohol, GI bleed, – Poor oral intake or vomiting
What is a differential dx?What is a differential dx?
Hyperglycemia: DKA, HONKs, glucose administration
Ketoacidosis: DKA, AKA, starvation, 3rd trimester pregnancy
AGMA: AMUDPILECATO Hyperglycemia + Ketoacidosis + AGMA = DKA
– There isn’t really a ddx– HONKS could potentially fool you b/c ketoacidosis can
be present but it should be MINIMAL/MILD
Is there any value in Is there any value in measuring serum ketones?measuring serum ketones?
Maybe! Serum ketones measures betahydroxybutyrate Urine dip for ketones measures acetoacetate Acetoacetate rises EARLIER but
betahydroxybutyrate rises HIGHER in DKA– Acetoacetate: betahydroxybutyrate ratio normally 1:3– Can be as high as 1:30– Could potentially have –ve urine dip for ketones
despite very high levels of betahydroxybutyrate
How will you manage the DKA How will you manage the DKA patient?patient?
FluidsInsulinElectrolyte disordersLook for precipitantGenerally no bicarbChemstrip q1hr, lytes q2hr initially
Fluid management of DKAFluid management of DKA
ADULT– Principles
DKA develops in days and can does NOT need to be reversed within hours unless very unstable
Some evidence that too rapid fluid rehydration decreases serum osmolarity too fast and causes cerebral edema
– NS boluses for shock– Otherwise give 2-3L NS over 2 hours (slower with CHF/CRF)
– Some advocate 1/2NS or colloid but most use NS (1/2NS decreases osmolarity faster)
– Switch to D51/2NS when glucose 14-16 and decrease rate to 2X maintenance
Insulin and DKAInsulin and DKA
Humulin R iv Bolus 0.1 unit/kg: ?????Humulin R iv Infusion 0.1 unit/kg/hr
– Must prime tubing– Adjust infusion as glucose drops– Chemstrips q1hr – Target drop in 2-3 mmol/hr– Note: low doses as effective as higher doses
with less complications
Bolus insulin?Bolus insulin?
Controversial No RCT to compare bolus vs no bolus Recommendations change Don’t give a bolus in peds CMAJ Review article April 2003
– No evidence to recommend an iv bolus Diabetes Care26: Supplement. 2003
– Concensus statement from American Diabetic Association– Recommends iv bolus 0.15 Unit/kg iv for adults but not
peds
CaseCase
You have initiated fluid resuscitation and started Humulin R at 0.1 U/kg/hr
One hour later the c/s is still 25Why? What do you do?
– Insulin resistance– Double the infusion rate, recheck glucose in
one hour, double rate q hourly until glucose is dropping by 2-3 mmol/hr
Electrolyte disorders inDKAElectrolyte disorders inDKA
What disorders do you expect?
How are they managed?
Hypokalemia– Always deficient in K+– Ensure urine output b/f replacing– K+ > 5.0: no K+, recheck in 1hr– K+ 4 – 5: 20 mmol KCl/L– K+ 3 – 4: 40 mmol KCl/L– K+ < 3: 60 mmol KCl/L or iv
bolus
Electrolyte disorders: Electrolyte disorders: disorders of Na, Mg, P04 commondisorders of Na, Mg, P04 common
Na– False: dilutional b/c of hyperosmolarity (10:3)– True: vomiting, poor intake, renal loss– No specific mx
Mg– Level may be low, normal, or high b/c shift– Total body depletion common: replace 2gm iv
P04– Level may be low, normal, or high b/c shift– Total body depletion common– Generally no need to replace unless very low or
complications (resp depression, arrythmias)
Case: she’s sick, pH was Case: she’s sick, pH was 6.95, would you give bicarb?6.95, would you give bicarb?
Controversial: NO RCT Glaser NEJM Jan 2001: retrospective study of cerebral edema
in peds DKA– Predictors: bicarb, lower C02, higher BUN
Adults– Give bicarb if pH < 7.0 AFTER 1hr of fluids– How: 100 mmol sodium bicarb to 400 ml of sterile water
and run at 200 ml/hr Peds
– CMAJ: Don’t give bicarb– ADA: consider bicarb if pH<6.9 after 1hr of fluids– 1-2 mEq/kg added to NS (max sodium is 155 mEq/L)
CaseCase
5hrs in ED waiting for bed
RN calls you to bedside
She’s confused Dx? Mx?
CEREBRAL EDEMA More common in peds (1%) 50% of mortality of DKA 6-10 hrs after initiation of tx Mechanism unknown: shifts? Highest risk
– New dx, < 5yo, pH < 7.1 Predictors (Glaser)
– Bicarb, low C02, high BUN
DKA: Cerebral EdemaDKA: Cerebral Edema
Presentation– Failure to improve LOC
with treatment– Deterioration of LOC
despite treatment– Seizures– Pupillary changes (unequal,
unresponsive)– Hemodynamic instability– Decrease u/o despite fluids
Management– ABCs– Elevate head of bed– Hyperventilate– Mannitol ?– Decrease iv rate– ICU– NO steroids
What’s different in adult vs What’s different in adult vs pediatric DKApediatric DKA
The same principles but more cautious on the fluids, no insulin bolus, no bicarb, insulin started if in ED > 2hrs (fluids before insulin)
Mild: pH >7.25, C02 >12, normal LOC, <10% dry– NS at 1.5X maintenance (no bolus)
Mod: pH 7.15-7.25, C02 8-12, 10-15% dry– NS bolus 10 cc/kg then 1.5X maintenance
Severe: pH , 7.15, C02 < 8, > 15% dry or shocky– NS bolus 20 cc/kg X 1 or until shock resolves– Then NS at 1.5X maintenance
CaseCase
85 yo female Dementia Nursing home More confused RN did chemstrip = 30 Tachy, hypotensive,
GCS 12, parched
Glucose 55 K+ 5 C02 19 BUN 25 Urine glucose 3+ Urine ketones 1+ Dx? Mx?
HONKSHONKS
HHNKs, HHS Pathophysiology
– Relative lack of insulin (enough to prevent significant ketoacidosis though)
– Physiologic stress– Hyperglycemia– Profound osmotic diuresis and dehydration– Compounded by poor oral intake
Dementia, CVA, mental illness, mentally challenged, SCI, hip #, elderly, etc
HONKSHONKS
Features– Usually elderly,
dementia, CVA, etc– Very, very dry– Severe hyperglycemia– Minimal or absent
ketoacidosis– Any CNS finding
Precipitants to consider– Sepsis– CVA– Fall, hip#, trauma– Ischemia, MI– Poor oral intake– Drugs
Diuretics Dilantin
HONKS managementHONKS management
Treat essentially the same as DKA Fluids: deficit larger (10L)
– Bolus prn for shock– Replace ½ deficit over 8hrs and ½ over 16hrs– Most use NS X 2-3L then switch to ½ NS– Slower rates with CRF and CHF– Switch to D5 ½ NS when glucose 14-16– Case reports of cerebral edema with fast replacement
Insulin: controversial, safe and effective, +/-bolus Manage electrolyte disorders; No bicarb
CaseCase
She has a generalized seizure What are you thinking as an etiology?
– Could be any cause: structural vs metabolic– Think of CNS events, cerebral edema, rapid lyte
changes, hypoglycemia from insulin
Management after correcting lytes, glucose prn?– Benzodiazepines, phenobarb 2nd line– NO dilantin
Can cause HONKS b/c inhibits release of insulin
Compare and Contrast:Compare and Contrast:DKA, HONKS, AKADKA, HONKS, AKA
DKA HONKS AKAGluc 20-25 50-60 2-8
C02 < 10 18-22 10-15
Ketones large None or small Large
Urine ketones 3+ 0 or 1+ 3+
Osm 320 380 320
Vol def 3-5L 10-12L 3-5L
Age young old middle
CaseCase
Glucose of 1.9 Not known to be
diabetic Ddx? Investigations? Mx?
Non-diabetic HypoglycemiaNon-diabetic Hypoglycemia
Insulinoma Insulin Oral hypoglycmics Sepsis Critical Illness Liver Failure Adrenal failure Alimentary
hyperinsulinism
Labs– Insulin level– Pro-insulin level– Cpeptide level– Sulphonyurea– LFTs, cortisol
Mx– IV Dextrose– Glucagon: 1-2 mg im
or sc
Etiology of Thyroid Etiology of Thyroid EmergenciesEmergencies
Undiagnosed or Undertreated thyroid disorder
(hypo or hyperthyroid)
Acute Precipitant
ThyroidStormOr Myxedemic coma
KEY FEATURES of Thyroid StormKEY FEATURES of Thyroid Storm
FEVERTACHYCARDIAALTERED LOCFeatures of underlying Hyperthyroidism
– Weight loss, heat intolerance, tremors, anxiety, diarrhea, palpitations, sweating, CP, SOB
– Goiter, eye findings, pretibial myxedema
When should you consider Thyroid When should you consider Thyroid Storm and what is the ddx?Storm and what is the ddx?
Infectious: sepsis, meningitis, encephalitisVascular: ICH, SAHHeat strokeToxicologic
– Sympathomimetics, seritonin syndrome, neuroleptic malignant syndrome, Delirium Tremens, anticholinergic syndrome
Summary of Thyroid Storm Summary of Thyroid Storm ManagementManagement
PTU: 1gm po then 250 q4hr PROPRANOLOL: 1-2mg iv q10min POTASSIUM IODIDE: SSKI 5
drops po q6hr STERIODS: dexamethasone 4mg iv SUPPORTIVE CARE
P3S2
KEY FEATURES of KEY FEATURES of MyxedemaMyxedema
ALTER ED LO C H YPO VEN TILATIO N /R ESP FA ILU R E
H YPO TH ER M IA
U nderlying/preceeding featuresof H ypothyro id ism
When should Myxedema be When should Myxedema be considered and what is the ddx?considered and what is the ddx?
Altered LOC– Structural vs metabolic causes of decreased LOC
Hypoventilatory Resp Failure– Narcotics, Benzodiazepines, EtOH intoxication, OSA,
obesity hypoventilation, brain stem CVA, neuromuscular disorders (MG, GBS)
Hypothermia– Environmental– Medical: pituitary or hypothalamic lesion, sepsis
Management of Myxedemic Management of Myxedemic ComaComa
Levothyroxine is the cornerstone of Mx– Levothyroxine 500 ug po/iv (preferred over T3)– Ischemia and arrythmias possible: monitor– When in doubt, treat en spec
Other– Intubate/ventilate prn– Fluids/pressors/thyroxine for hypotension– Thyroxine for hypothermia– Stress Steroids: hydrocortisone 100 mg iv
Etiology of Adrenal CrisisEtiology of Adrenal Crisis
Underlying Adrenal Insufficiency
(Addision’s and Chronic Steriods)
Acute Precipitant
AdrenalCrisis
Key Features of Adrenal CrisisKey Features of Adrenal Crisis
Nonspecific– Nausea, vomiting,
abdominal pain
Shock– Distributive shock not
responsive to fluids or pressors
Laboratory (variable)– Hyponatremia,
hyperkalemia, metabolic acidosis
Known Adrenal insufficiency
Features of undiagnosed adrenal insufficiency– Weakness, fatigue,
weight loss, anorexia, N/V, abdo pain, salt craving, hyperpigmentation
Adrenal CrisisAdrenal Crisis
Consider on the differential diagnosis of SHOCK NYD
Management of Adrenal CrisisManagement of Adrenal Crisis
Corticosteroid replacement– Dexamethasone 4mg iv q6hr is the drug of
choice (doesn’t affect ACTH stim test)– Hydrocortisone 100 mg iv is an option– Mineralocorticoid not required in acute phase
Other– Correct lytes, fluid resuscitation (2-3L)– Glucose for hypoglycemia
The end…….The end…….