Endocrine Emergencies

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Endocrine Emergencies

• David C. Seaberg, MD, FACEP
• Department of Emergency Medicine

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Endocrine Emergencies

• Hypoglycemia
• DKA
• Hyperosmolar Non-ketotic Coma (HONK)
• Lactic Acidosis
• Hypothyroidism
• Hyperthyroidism
• Pheochromocytoma
• Addisons Disease

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Glucose Metabolism

• Food intake
• Glucose stimulates insulin
• Insulin converts glucose into glycogen
• Insulin also
• inhibits gluconeogenesis
• enhances lipogenesis, restrains lipolysis
• enhances uptake of amino acids into muscle

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HypoglycemiaCauses

• Endogenous
• Fed
• early DM
• idiopathic
• Fasting
• Islet-cell tumor
• Endocrine deficiency
• Hepatic disease
• Starvation
• Chronic renal failure

• Exogenous
• Insulin
• Factitious
• Alcohol
• Drugs

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Hypoglycemia

• Factitious vs. Islet-cell tumor
• Proinsulin breaks down into insulin and
  C-peptide, in equal amounts
• Factitious will have insulin antibodies

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Hyperglycemia

• Diabetic ketoacidosis
• Hyper osmolar non-ketotic coma (HONK)

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Hyperglycemia
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Hyperglycemia

• Insulin lack
• Symptoms
• polyuria, polydipsia, N/V
• Kussmaul breathing, dry skin, acetone breath
• Glycolysis, lipolysis
• 3 ketones
• acetone, acetoacetate, ?-hydroxybutyrate

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DKA

• Causes
• infection most common
• silent MI, CVA, decreased insulin intake, drugs,
  pregnancy, pancreatitis
• Average fluid deficit 6-8 liters

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DKA

• Labs
• ? glucose
• ? bicarb, ? potassium, ? pH
• Increased anion gap
• AG Na - (Cl HCO3) 12 4mEq/L

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Anion Gap Metabolic Acidosis

• Aspirin/AKA
• Methanol
• Uremia
• DKA
• Paraldeyde
• INH/Iron
• Lactic acidosis
• Ethylene glycol

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DKA

• Treatment
• Fluid
• Insulin
• Avoid high-dose insulin
• delayed hypoglycemia
• delayed hypokalemia
• ? Bicarbonate
• Watch Potassium
• Watch Phosphate

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Nonketotic Hyperosmolar Coma

• Like DKA hyperglycemia, hyperosmolar
• Lacks ketoacidosis
• Blood glucose gt 800
• Serum osmolality gt 350
• negative serum ketones
• 2/3 of pts have no h/o diabetes
• Average fluid deficit 9 liters

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Nonketotic Hyperosmolar Coma
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Nonketotic Hyperosmolar Coma

• Serum osmolality
• 2 Na glucose/18 BUN/2.8
• 50 may have metabolic acidosis due to
• lactate, ß-hydroxybutyrate, renal insufficiency

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Drugs and Procedures that cause Nonketotic
Hyperosmolar Coma

• Thiazide diuretics
• lasix
• diazoxide
• Ca channel blockers
• glucocorticoids
• dilantin
• thorazine

• Tagamet
• inderal
• mannitol
• peritoneal dialysis
• hemodialysis

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Neurological Manifestations of Nonketotic
Hyperosmolar Coma

• Diffuse
• Seizures
• Lethargy
• Confusion
• Delerium/hallucinations
• Stupor
• Coma

• Focal
• Focal seizures
• Todds paralysis
• hemiparesis
• aphasia
• hemianpsia
• nystagmus
• hyperrelexia
• choreoathetosis

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Nonketotic Hyperosmolar Coma

• Treatment
• Saline isotonic vs. hypotonic
• 2 liters in first 2 hours
• may need CVP or PCWP to monitor
• Insulin
• Glucose - add when serum glucose lt 250
• Phosphorus
• Watch Potassium

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Alcoholic Ketoacidosis

• Mechanism unknown
• Ketosis form increased mobilization of FFA
• Increased liver metabolism
• Increased anion gap with high levels of ketoacids

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Alcoholic Ketoacidosis

• Symptoms
• alcohol intake, decreased food intake
• Abdominal pain
• dehydration
• N/V
• Lab
• WAGMA
• Glucose lt 300, sometimes normal or low

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Alcoholic Ketoacidosis

• Lab
• Ethanol level 0
• measured serum ketones may be normal
• Nitroprusside reaction only measures acetone and
  acetoacetate
• ß-hydroxybutyrate is main ketone formed in AKA

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Alcoholic Ketoacidosis

• Treatment
• Saline
• Glucose
• Thiamine

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Lactic Acidosis

• Most common metabolic acidosis
• Type A
• tissue anoxia
• hypotension, hypoxia
• Type B
• Disorders DM, RF, Infection, Liver dz,
  malignancy
• Drugs/Toxins biguanides, methanol,
• Hereditary glycogen storage dz

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Lactic Acidosis

• Treatment
• Restore circulation
• Bicarbonate?

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Thyroid Storm

• Most often seen with moderate to severe
  antecedent Graves Disease
• Precipitating factors
• infection, DKA,
• Symptoms
• tachycardia out of proportion to fever
• GI symptoms anorexia, N/V, abdominal pain
• CNS disturbances
• Cardiovascular arrythmias, A-fib, PVCs, CHF

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Hyperthyroidism
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Thyroid Storm

• Lab
• no lab tests confirm throid storm
• elevated T3 and T4
• Increased RAI uptake

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Apathetic Thyrotoxicosis

• Elderly patients
• thryoid storm without hyperkinetic manifestations
• Sx
• lethargy, slowed mentation, apathetic facies,
  goiter
• absence of exophthalmos but may have drooping of
  upper eyelid
• wt loss and muscle weakness
• A-fib

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Thyroid Storm Treatment

• General supportive care
• saline, avoid aspirin
• Inhibit thyroid hormone synthesis
• PTU, 900 - 1200 mg
• Retard thyroid hormone release
• KI, 1g q8-12 hr
• Block peripheral effects
• ß-blockers
• glucocorticoids

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Myxedema Coma Primary Hypothyoidism (Thyroid)

• previous thyroid operation
• goiter present
• hypothermia
• coarse voice
• sella turcica normal

• cardiomegaly
• normal menses
• dry skin
• no response to TSH
• good response to levothyroxine
• increased TSH

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Myxedema Coma Secondary Hypothyoidism
(Pituitary)

• No previous thyroid operation
• no goiter present
• less hypothermia
• coarse less voice
• sella turcica increased
• plasma cortisol level decreased

• small heart size
• abnormal menses
• skin fine and soft
• good response to TSH
• poor response to levothyroxine
• decreased TSH

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Myxedema Coma

• precipitating cause
• 80 are hypothermic
• respiratory failure
• hyponatremia
• cardiomegaly
• pericardial effusion
• coma
• megacolon

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Myxedema
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Myxedema Coma

• Treatment
• Supportive
• rewarm
• ventilatory support
• treat precipitating cause
• hydrocortisone, 300mg/d
• Thyroid hormone
• thyroxine, 400-500 ug, iv

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Adrenal Crisis

• Adrenal Hormones
• Cortisol - major glucocorticoid
• Aldosterone - mineralocorticoid
• Androgens

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Primary Adrenal Insufficiency

• Primary, chronic
• idiopathic
• infiltrative or infectious (TB, sarcoid,
  hemochromatosis)
• hemorrhagic
• drugs
• Primary, acute
• Hemorrhage - septicemia, newborn
• discontinue steroid replacement

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Secondary Adrenal Insufficiency

• Secondary, chronic
• pituitary tumor
• infiltrative or granulomatous (sarcoid,
  hemochromatosis)
• pituitary hemorrhagic
• internal carotid aneurysm
• head trauma
• infection (meningitis, sinus thrombosis)
• Secondary, acute
• discontinue steroid replacement

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Primary vs. Secondary

• In secondary, pituitary is unable to secrete ACTH
  however aldosterone is unaffected
• Secondary has insufficiency of cortisol and
  adrenal androgens
• Secondary may have failure of other pituitary
  hormones

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Addisons Disease Primary Adrenal Insufficinecy

• 90 of adrenal cortex must be involved
• Sx
• anorexia, N/V, lethargy, , weakness
• wt loss, abdominal pain, diarrhea
• postural hypotension, syncope
• may have altered mental status
• pigmentation (lack of ACTH)

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Addisons Disease
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Addisons Disease
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Addisons Disease Primary Adrenal Insufficinecy

• Lab
• hyponatremia
• hyperkalemia
• hypoglycemia
• azotemia
• EKG
• flat/inverted T waves, low voltage, prolonged QT,
  hyperkalemia changes

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Addisons Disease Primary Adrenal Insufficinecy

• Diagnosis
• low baseline cortisol levels
• poor response to ACTH
• ACTH (corticotropin) stim test - max response at
  1 hr

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Addisons Disease Primary Adrenal Insufficinecy

• Treatment
• 1. Supportive
• saline, glucose
• 2. Hormone replacement
• Glucocorticoid 20 - 37.5 mg/day
• Mineralocorticoid
• Florinef, 0.05 - 0.2mg/day
• Androgen
• fluoxymesterone, 2-5 mg/day

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Pheochromocytoma

• Tumor of adrenal medulla
• Release epinephrine and norepinephrine
• Acute hypertensive crisis - 90
• Often precipitating factors
• exercise, anethetics, MAOI, surgery, tyramine
• Other sx sweating, heat intolerance, wt loss,
  hyperglycemia, orthostasis

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Pheochromocytoma
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Pheochromocytoma

• Treatment - antihypertensives
• Alpha-blockers
• phentolamine 2 - 5 mg q5 min
• phenoxybenzamine
• Nitroprusside
• Labetalol
• Avoid beta-blockers initially
• Surgery