Endocrine Emergencies

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Endocrine Emergencies

• Resident Rounds
• May 22, 2003
• Rob Hall PGY3

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Outline
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Case

• 16yo female, DM1
• Drinking, ecstacy at a rave, no insulin
• Confused, dry, borderline hypotension, tachy
• Chemstrip 25
• Urine gluc/ketoneve
• Fruity breath

• Na 129
• K 5.1
• HCO3 8
• pH 6.95
• PC02 20
• Mg low
• P04 low

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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

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What is a differential dx?

• Hyperglycemia DKA, HONKs, glucose administration
• Ketoacidosis DKA, AKA, starvation, 3rd trimester
  pregnancy
• AGMA AMUDPILECATO
• Hyperglycemia Ketoacidosis AGMA DKA
• There isnt really a ddx
• HONKS could potentially fool you b/c ketoacidosis
  can be present but it should be MINIMAL/MILD

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Is there any value in 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
  13
• Can be as high as 130
• Could potentially have ve urine dip for ketones
  despite very high levels of betahydroxybutyrate

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How will you manage the DKA patient?

• Fluids
• Insulin
• Electrolyte disorders
• Look for precipitant
• Generally no bicarb
• Chemstrip q1hr, lytes q2hr initially

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Fluid 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

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Insulin 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

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Bolus insulin?

• Controversial
• No RCT to compare bolus vs no bolus
• Recommendations change
• Dont 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

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Case

• You have initiated fluid resuscitation and
  started Humulin R at 0.1 U/kg/hr
• One hour later the c/s is still 25
• Why? 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

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Electrolyte disorders inDKA

• What disorders do you expect?
• How are they managed?

• Hypokalemia
• Always deficient in K
• Ensure urine output b/f replacing
• K gt 5.0 no K, recheck in 1hr
• K 4 5 20 mmol KCl/L
• K 3 4 40 mmol KCl/L
• K lt 3 60 mmol KCl/L or iv bolus

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Electrolyte disorders disorders of Na, Mg, P04
common

• Na
• False dilutional b/c of hyperosmolarity (103)
• 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)

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Case shes sick, pH was 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 lt 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 Dont give bicarb
• ADA consider bicarb if pHlt6.9 after 1hr of
  fluids
• 1-2 mEq/kg added to NS (max sodium is 155 mEq/L)

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Case

• 5hrs in ED waiting for bed
• RN calls you to bedside
• Shes 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, lt 5yo, pH lt 7.1
• Predictors (Glaser)
• Bicarb, low C02, high BUN

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DKA 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

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Whats different in adult vs pediatric DKA

• The same principles but more cautious on the
  fluids, no insulin bolus, no bicarb, insulin
  started if in ED gt 2hrs (fluids before insulin)
• Mild pH gt7.25, C02 gt12, normal LOC, lt10 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 lt 8, gt 15 dry or shocky
• NS bolus 20 cc/kg X 1 or until shock resolves
• Then NS at 1.5X maintenance

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Case

• 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?

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HONKS

• 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

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HONKS

• 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

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HONKS 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

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Case

• 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

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Compare and ContrastDKA, HONKS, AKA
DKA HONKS AKA
Gluc 20-25 50-60 2-8
C02 lt 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
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Case

• Glucose of 1.9
• Not known to be diabetic
• Ddx?
• Investigations?
• Mx?

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Non-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

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Etiology of Thyroid Emergencies
Thyroid Storm Or Myxedemic coma

• Undiagnosed or
• Undertreated
• thyroid disorder (hypo or hyperthyroid)

Acute Precipitant
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KEY FEATURES of Thyroid Storm

• FEVER
• TACHYCARDIA
• ALTERED LOC
• Features of underlying Hyperthyroidism
• Weight loss, heat intolerance, tremors, anxiety,
  diarrhea, palpitations, sweating, CP, SOB
• Goiter, eye findings, pretibial myxedema

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When should you consider Thyroid Storm and what
is the ddx?

• Infectious sepsis, meningitis, encephalitis
• Vascular ICH, SAH
• Heat stroke
• Toxicologic
• Sympathomimetics, seritonin syndrome, neuroleptic
  malignant syndrome, Delirium Tremens,
  anticholinergic syndrome

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Summary of Thyroid Storm Management

• P3S2

• PTU 1gm po then 250 q4hr
• PROPRANOLOL 1-2mg iv q10min
• POTASSIUM IODIDE SSKI 5 drops po q6hr
• STERIODS dexamethasone 4mg iv
• SUPPORTIVE CARE

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KEY FEATURES of Myxedema
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When should Myxedema be 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

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Management of Myxedemic Coma

• 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

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Etiology of Adrenal Crisis

• Underlying Adrenal Insufficiency
• (Addisions and Chronic Steriods)

Acute Precipitant
Adrenal Crisis
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Key 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

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Adrenal Crisis

• Consider on the differential diagnosis of SHOCK
  NYD

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Management of Adrenal Crisis

• Corticosteroid replacement
• Dexamethasone 4mg iv q6hr is the drug of choice
  (doesnt 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

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The end.