Endocrine Emergencies

Name a Few… DKA HONK (HHOS) Addisonian crisis Thyroid storm Myxoedemic coma

What’s the Diagnosis? 83yr woman with 3/7 histroy of malaise and polyuria. PMH type I DM and HTN HR 100, BP 100/60, GCS 14, SaO2 100% on high flow O2 Na 125 K 6.0 Cl 81 HCO3 7 Ur 25 Cr 262 Glu 54.5 Osmolality 337

DKA Definition Mortality 5-15% (less in children) BSL increased Ketones present Anion gap >10 HCO3 <15 pH <7.3 Mortality 5-15% (less in children) Beware if pregnant: 30-50% mortality

All About Ketones Beta-hydroxybutyrate Acetoacetate Acetone Detected by Medisense blood test Higher in alcoholic ketoacidosis than in DKA Acetoacetate >6x the levels of above AFTER conversion (ie. May initially be negative) measured by Ketostix urine test Acetone Detected on Acetest Responsible for ketotic breath How do ketones impact on management? Endpoint = ketones cleared, normal anion gap

Other Vital Stuff VBG Anion gap metabolic acidosis Maybe metabolic alkalosis (vomiting), resp alkalosis (hyperventilation) BSL How does BSL impact on management? Aim decr no more than 5/hr Na… How do I calculate corrected Na???? Average deficit 5-10mmol/kg Na + ( (Glu – 5.5) / 3 ) So if Na is 128 and Glu is 65 – what is real Na? How does Na impact on management? K… How do I correct K for pH???? Average deficit 3-5mmol/kg Decr pH by 0.1 = Incr K by 0.5 So if pH is 7 and K is 5.7 – what is real K? How does K impact on management? Osmolality… How do I calculate osmolality? Average body H20 deficit 100ml/kg Do I even have to? Can’t I just measure it?? (ie. 10% dehydration) (2 x Na) + Glucose + Urea How does osmolality impact on management? Aim decr by no more than 1-2/hr Any other investigations? ?precipitant; ?ARF; ?level of long-term control

Let’s look at that gas again… Na 125 K 6.0 Cl 81 HCO3 7 Ur 25 Cr 262 Glu 54.5 Osmolality 337

Management of DKA It’s bloody confusing and hard to remember Split into… 1) IV fluids 2) Potassium 3) Insulin 4) NaHCO3

Fluids Adult Child 1L stat 10-20ml/kg bolus  rpt until haemodynamically stable 1L over 1hr Replace deficit over 48hrs  1L over 2hrs  1L over 4hrs Deficit = %dehydration x weight x 10  1L over 10hrs Use N saline Use 0.45% saline Use 0.45% saline and correct over 72hrs if Na >150 / Osm >320 if Na >150 / Osm >320 Watch: Na, osmolality, BSL Change to 0.45% saline + 5% dex when BSL <15 and also if….. BSL decreasing too fast (ie. >5/hr) BSL <10 but ketones ongoing

Potassium How do you correct for pH again? Only add K in 2nd hour / once UO / K <5 Adult K 4-5 = 10mmol/hr K 3-4 = 30mmol/hr K <3 = 40mmol/hr Child Add 40mmol to 1L bag

Insulin Start after 1hr of fluids if K >3.4 (otherwise replace K first) Do you give a stat dose of actrapid? Actrapid infusion 0.1iu/kg/hr (max 6iu/hr) Decrease to 0.05iu/kg hr if…. BSL <12 (stop for 15mins if still too low despite this) Aim for BSL decrease of no more than 5/hr K <3

NaHCO3 What are the indications? What is the dose? pH <7 HCO3 <5 Life threatening hyperkalaemia Coma Haemodynamic compromise unresponsive to IV fluids What is the dose? 0.5 – 2mmol/kg over 1-2hrs What is the endpoint? pH >7.1 HCO3 >10 What are the risks? Worsened intracellular acidosis, hypokalaemia, hypernatraemia, osmolar shifts and cerebral oedema, volume overload

Cerebral oedema 70% mortality; 10% have ongoing neuro deficit; more common in children Onset 4-12hrs after starting trt What are the symptoms? Headache, decr LOC, decr HR, incr BP, pupil changes, seizure, urinary incontinence How do you treat it? Mannitol 0.5-1g/kg 3% saline 5-10ml/kg over 30mins Half maintenance fluids

Hyperglycaemic Hyperosmolar State DKA HHOS Mortality up to 15% Mortality up to 45% BSL + BSL ++++ pH <7.3 pH >7.3 Anion gap >12 Anion gap <12 HCO3 <15 HCO3 >15 Ketones ++++ Ketones -/+ Maybe incr osmolality Osmolality >320-350 H20 deficit 100ml/kg (10% dehydration) H20 deficit more (20-25% dehydration) Higher Na + K deficit Resus with N saline Use N saline thereafter unless Na >150 / Osm >320 Use 0.45% saline thereafter (unless low corrected Na) Change to 0.45% saline + 5% dex when BSL <15 Replace deficit over 48hrs Replace deficit over 48-72hrs Similar K replacement Actrapid 0.1iu/kg/hr (max 6iu/hr) Actrapid 0.05iu/kg/hr (max 3iu/hr) Heparin important (hypercoag state)

What’s the diagnosis (bearing in mind this is an endocrine talk)? An 85 year old man is brought to your Emergency Department fitting. His family say that he has been lethargic and weak for the last two weeks. He has a PMH of polymyalgia rheumatica. These are his initial biochemistry results. Na 99 mmol/L K 5.9 mmol/L Cl 68 mmol/L BSL 2.2mmol/L HCO3 - 21 mmol/L Urea 10.1 mmol/L Cr 180 umol/L pH 7.1 Anion gap normal pCO2 31 mmHg pO2 149.5 mmHg BE 2.4 HCO3 17.6 mmol/L

Addisonian Crisis Back to Part One’s!! Effects of cortisol Incr BSL (gluconeogenesis, lipolysis, decr ketogenesis, decr insulin release) Effects of aldosterone Incr Na (incr reabsorption) Decr K (incr excretion in DCT) Alkalosis (incr H excretion) So…. what changes may be seen on bloods in view of the above? Dehydration – fluid resistant hypotension Decr osmolality Decr BSL Decr Na, Cl Incr K Non-anion gap metabolic acidosis If 2Y hypoadrenalism patient euvolaemic with lower K, as aldosterone is still working

Recognising Addisonian Crisis Who gets it? 1Y Long-term steroids stopped abruptly Adrenal haemorrhage (neonates, anticoagulated folk, sepsis (name the syndrome), trauma) Addison’s disease Prior surgical removal Adrenal destruction due to other cause: infection (eg. TB, HIV, CMV), thrombosis, metastatic Ca 2Y Head trauma Meningitis In pregnancy (name the syndrome). Pituiary failure How do they present? Hypotension, lethargy, weight loss, weakness, N+V, abdo pain, diarrhoea Ie. Non-specifically unwell and not responding to conventional treatment plus characteristic electrolyte changes Freidrick – waterhouse Sheehan syndrome

Management Investigation Management Name the investigation IV fluids ++++ (vasopressors may be needed) Dextrose Treat K if needed Dexamethasone 10mg IV stat (give initially as doesn’t interfere with investigations) …then hydrocortisone 250mg IV stat ACTH stimulation test, synacthen then look at cortisol = 1Y will not have cortisol rise, 2Y will ACTH Free cortisol levels

What’s the diagnosis? 17yr old female presents feeling anxious, unwell, tremulous, hyperventilating, looking flushed. Recent history of abdominal pain and diarrhoea. HR 130, T 38, BP 140/87, RR 24 On examination: gallop rhythm, bibasal crepitations, abdomen SNT pH 7.8 PCO2 15 mmHg PO2 192 mmHg (75-100)

Thyroid Calamities Back to Part One’s again! Effect of T3+4 Incr metabolism Incr GI motility Incr glucose absorption Incr sensitivity to epinephrine and norepinephrine, increased beta-receptors

Thyroid Storm Clinical diagnosis – labs don’t differentiate Mortality 10% treated, 90% untreated with death due to CV collapse Who gets it? Undiagnosed Graves Meds – XS thyroxine / withdrawal from anti-thyroid drugs / iodine or contrast Stressor – MI, DKA, OT

Recognising Thyroid Storm Diagnostic criteria Fever >37.8 Incr HR out of proportion to fever (ie. >120) CNS disturbance (eg. Altered LOC, seizures) Other AP, N+V, diarrhoea, high output CCF (wide pulse pressure, S3 gallop rhythm), HTN, dehydration, sweating Investigations – non-specific

Management A + B C Treat cause Definitive treatment Supportive care Give O2 as consumption increased C IV fluids containing dextrose Cardioversion better than drugs for arrhythmias Treat cause Definitive treatment Esmolol 250-500mcg/kg bolus  infusion (safe as short half life; titratable; blocks cardiac and peripheral effects and slows conversion of T3 to T4) If less severe can use PO propanolol Hydrocortisone 100mg IV (slows conversion of T3 to T4 and decreases hormone release) Propylthiouracil / methimazole / iodide Supportive care Ongoing fluids, monitor electrolytes and BSL, treat fever

What’s the Diagnosis? (This was an actual patient I saw last week) 58yr old man with non-specific malaise PMH: hyperthyroidism treated with radioactive iodine; known to be non-compliant with treatment OE: normal observations; mild oedema around eyes; examination otherwise unremarkable

Myxoedema Coma Who’s ever seen one??? Mortality 50%; same triggers as thryoid storm Symptoms A: hoarseness, glottic oedema B: decr RR C: decr BP, CCF D: decr LOC, hypothermia without shivering, seizures E: hypoglycaemia, paralytic ileus Management ABC, treat cause T3 has rapid effect, T4 has smoother improvement, give hydrocortisone Monitor electrolytes esp Na and titrate fluids accordingly Rewarming

Anything else you want to talk about…? Hyponatraemia? Hypernatraemia? Metabolic acidosis? Sodium bicarb use?