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…….