2. Endocrine Emergencies Prof. Mohamad S. Al-Hadramy Professor of Medicine/Consultant Prof. Mohamad S. Al-Hadramy Professor of Medicine/Consultant

3. ENDOCRINE EMERGENCIES

4. Hypoglycemia DKA Non-ketotic hyperosmolar diabetic coma Adrenal crisis S I A D H Myxoedema coma Thyroid storm Hypoglycemia DKA Non-ketotic hyperosmolar diabetic coma Adrenal crisis S I A D H Myxoedema coma Thyroid storm

5. A 50-year-old lady, T2DM, on Metformin and glibenclamide, well controlled. She had URTI and was given Ofloxacin 500 mg OD. She was brought to ER with acute confusion. She was porfusely sweating and looked pale. A.What is the diagnosis? B.How is this different from other causes of coma in a diabetic patient? A 50-year-old lady, T2DM, on Metformin and glibenclamide, well controlled. She had URTI and was given Ofloxacin 500 mg OD. She was brought to ER with acute confusion. She was porfusely sweating and looked pale. A.What is the diagnosis? B.How is this different from other causes of coma in a diabetic patient?

6. Initial treatment If conscious: sugar containing fluids, candy bars If unconscious: 20-50 mls of D 50%, followed by D 5% or 10% to maintain glucose >100 mg/dl (5.6 mmol/l). More aggressive if expected to be prolonged (e.g., sulphonylureas, liver failure Initial treatment If conscious: sugar containing fluids, candy bars If unconscious: 20-50 mls of D 50%, followed by D 5% or 10% to maintain glucose >100 mg/dl (5.6 mmol/l). More aggressive if expected to be prolonged (e.g., sulphonylureas, liver failure Hypoglycemia:

7. If prone to recurrence at home, give family, 1 mg glucagon IM or S/C Hypoglycemia:

8. 1.Fluids 2.Insulin 3.K 4.Bicarb 5.Treat PPT 1.Fluids 2.Insulin 3.K 4.Bicarb 5.Treat PPT D K A

9. How does the patient usually present?

10. Admit, preferrably in ICU Monitor Glucose usually >250 mg/dl (13.9 mmol/l); less than 800 mg/dl (44.4 mmol/l). Check: vitals, volume status, metabolic status Admit, preferrably in ICU Monitor Glucose usually >250 mg/dl (13.9 mmol/l); less than 800 mg/dl (44.4 mmol/l). Check: vitals, volume status, metabolic status

11. Tests –Glucose –U/Es –Plasma osmolality Arterial blood gases, or mixed venous blood, P, Mg Monitor blood glucose Q 1 hour U/Es, plasma osmolality, Q 2 hour until stable Closure of anion gap [Na- (Cl + HCO3)] ≈ 12 ± 2 Tests –Glucose –U/Es –Plasma osmolality Arterial blood gases, or mixed venous blood, P, Mg Monitor blood glucose Q 1 hour U/Es, plasma osmolality, Q 2 hour until stable Closure of anion gap [Na- (Cl + HCO3)] ≈ 12 ± 2

12. 1.Fluids IV saline, 1L fast, followed by 1L/hour till volume deficiency is corrected. But, careful if cardiac decompensation. Monitor. Water deficit replaced by 0.45% saline at 150-500 ml/hour (N/saline if ↓ Na). Maintain fluids till +ve balance of 6 L (usually need 12 – 24 hours). When glucose is 200-250 mg/dl (11.1 – 13.9 mmol/l) change to 5 % D in 0.45 saline. 1.Fluids IV saline, 1L fast, followed by 1L/hour till volume deficiency is corrected. But, careful if cardiac decompensation. Monitor. Water deficit replaced by 0.45% saline at 150-500 ml/hour (N/saline if ↓ Na). Maintain fluids till +ve balance of 6 L (usually need 12 – 24 hours). When glucose is 200-250 mg/dl (11.1 – 13.9 mmol/l) change to 5 % D in 0.45 saline. D K A

13. 2.Insulin May be delayed if K <3.3 mmol/l. IV bolus of RI 10 – 15 U + continuous infusion by pump 0.1 u/kg/h Glucose will ↓by 50-75 mg/dl/hour (2.7 – 4.1 mmol/l/hour). Avoid reducing it by >100 mg/dl (5.6 mmol/l) per hour. Continue IV insulin till ketoacidosis resolved and glucose ≤ 200 mg/dl (11.1 mmol/l). Overlap IV with S/C by 30 minutes. 2.Insulin May be delayed if K <3.3 mmol/l. IV bolus of RI 10 – 15 U + continuous infusion by pump 0.1 u/kg/h Glucose will ↓by 50-75 mg/dl/hour (2.7 – 4.1 mmol/l/hour). Avoid reducing it by >100 mg/dl (5.6 mmol/l) per hour. Continue IV insulin till ketoacidosis resolved and glucose ≤ 200 mg/dl (11.1 mmol/l). Overlap IV with S/C by 30 minutes. D K A

14. 3.K Usually ↓K. Give IV K Cl 10 -20 meq/hour unless K >5.3 or renal failure or oliguria. If, K 3.3 and then start IV insulin. 3.K Usually ↓K. Give IV K Cl 10 -20 meq/hour unless K >5.3 or renal failure or oliguria. If, K 3.3 and then start IV insulin. D K A

15. 4.Bicarb Not given as routine. Considered if pH <7.1, HCO3 <7 meq/l or respiratory or cardiac dysfunction due to acidosis or severe ↑K. Give 50 meq HCO3 in 200 ml sterile water over 2 hours. If, PH <6.9, give 400 meq HCO3 in 400 mls sterile water over 2 hours. 4.Bicarb Not given as routine. Considered if pH <7.1, HCO3 <7 meq/l or respiratory or cardiac dysfunction due to acidosis or severe ↑K. Give 50 meq HCO3 in 200 ml sterile water over 2 hours. If, PH <6.9, give 400 meq HCO3 in 400 mls sterile water over 2 hours. D K A

16. 5.PPT factor(s): Antibiotics for infection M I etc. 5.PPT factor(s): Antibiotics for infection M I etc. D K A

17. More in elderly type 2. Glucose >500 mg/dl (33.3 mmol/l) Frequently >1000 mg/dl (55.6 mmol/l) No ketonemia More in elderly type 2. Glucose >500 mg/dl (33.3 mmol/l) Frequently >1000 mg/dl (55.6 mmol/l) No ketonemia Non-ketotic hyperosmolar coma:

18. 1.Fluids One (1) liter N Saline over 1 hour. Then: 0.45% saline if Na normal or raised, and if Na low, give normal saline at a rate of 250-500 ml/hour. If Na >155 mmol/l, give 5% Dextrose. Careful in elderly:- Cardiac compromise Make sure urine output around 50 ml/hour. Change to D5% in 0.45 saline if glucose 250 - 300 mg/dl (13.9 – 16.7 mmol/l). 1.Fluids One (1) liter N Saline over 1 hour. Then: 0.45% saline if Na normal or raised, and if Na low, give normal saline at a rate of 250-500 ml/hour. If Na >155 mmol/l, give 5% Dextrose. Careful in elderly:- Cardiac compromise Make sure urine output around 50 ml/hour. Change to D5% in 0.45 saline if glucose 250 - 300 mg/dl (13.9 – 16.7 mmol/l). Non-ketotic hyperosmolar coma:

19. 2.Insulin 5 – 10 u IV bolus, then 0.1 u/kg/hour by IV infusion pump. When glucose 300 mg/dl (16.7 mmol/l), reduce IV insulin to 0.05 u/kg/hour Maintain glucose 250 - 300 mg/dl (13.9 – 16.7 mmol/l) till osmolality <315. When mentally alert and able to feed, start S/C insulin. 2.Insulin 5 – 10 u IV bolus, then 0.1 u/kg/hour by IV infusion pump. When glucose 300 mg/dl (16.7 mmol/l), reduce IV insulin to 0.05 u/kg/hour Maintain glucose 250 - 300 mg/dl (13.9 – 16.7 mmol/l) till osmolality <315. When mentally alert and able to feed, start S/C insulin. Non-ketotic hyperosmolar coma:

20. 3.Correct Postassium 4.Treat underlying: Thromboembolism prophylaxis. 3.Correct Postassium 4.Treat underlying: Thromboembolism prophylaxis. Non-ketotic hyperosmolar coma:

21. A 45-year-old asthmatic lady was on long- term steroids for treating her severe asthma over the last year. She was using on her own 10 – 15 mg of prednisolone per day. She was admitted for cholecystectomy. Two days post-op, she started to have diffuse abdominal pain with nausea and vomiting. She was afebrile and her blood pressure was 90/50. She looked dehydrated. A.What is the diagnosis? B.How to confirm your diagnosis? A 45-year-old asthmatic lady was on long- term steroids for treating her severe asthma over the last year. She was using on her own 10 – 15 mg of prednisolone per day. She was admitted for cholecystectomy. Two days post-op, she started to have diffuse abdominal pain with nausea and vomiting. She was afebrile and her blood pressure was 90/50. She looked dehydrated. A.What is the diagnosis? B.How to confirm your diagnosis?

22. Secondary adrenal insufficiency expected after taking 30 mg of hydrocortisone per day or equivalent for >3 weeks. Adrenal crisis:

23. PPT:- stress –Infection. Tests: –U/Es –Glucose –Cortisol –ACTH PPT:- stress –Infection. Tests: –U/Es –Glucose –Cortisol –ACTH Adrenal crisis:

24. 1.IV fluids, if shock: 1 L of 5% Dextrose in N/Saline over 1 hour. Guided by correction of hypotension. 1.IV fluids, if shock: 1 L of 5% Dextrose in N/Saline over 1 hour. Guided by correction of hypotension. Adrenal crisis:

25. 2.IV hydrocortisone 100 mg Q 6 - 8 hours. ↓ gradually over several days M aintenance Hydrocortisone:- 10-15 mg AM / 5-10 mg PM Floudrocortisone 0.1 mg/day for 1 o Dexamethasone 10 mg IV if short synacthin test needed. 2.IV hydrocortisone 100 mg Q 6 - 8 hours. ↓ gradually over several days M aintenance Hydrocortisone:- 10-15 mg AM / 5-10 mg PM Floudrocortisone 0.1 mg/day for 1 o Dexamethasone 10 mg IV if short synacthin test needed. Adrenal crisis:

26. 1.Clinically euvolemic 2.Plasma osmolality <275. How to calculate it? 3.Inappropriate urinary concentration (i.e., urine osmolality >100 mosmol/kg H2O with normal renal function). 4.Elevated urinary Na >30 with normal salt and water intake. Does not rule in or out diagnosis. 5.Absence of other causes (e.g., hypopit, Adrenal failure). 1.Clinically euvolemic 2.Plasma osmolality <275. How to calculate it? 3.Inappropriate urinary concentration (i.e., urine osmolality >100 mosmol/kg H2O with normal renal function). 4.Elevated urinary Na >30 with normal salt and water intake. Does not rule in or out diagnosis. 5.Absence of other causes (e.g., hypopit, Adrenal failure). S I A D H:

27. Rapid correction  Pontine and extra pontine myelinolysis. Correct by IV hypertonic saline (or hypertonic), if severe acute (Na <120 meq/l) with CNS manifestations. If chronic and not severe, correct by fluid restriction. Rapid correction  Pontine and extra pontine myelinolysis. Correct by IV hypertonic saline (or hypertonic), if severe acute (Na <120 meq/l) with CNS manifestations. If chronic and not severe, correct by fluid restriction.

28. Donot correct Na by more than 1 – 2 mmol/l per hour, and not more than 12 mmol/l in the first 24 hours.

29. Myxoedema Coma and Thyroid Storm

30. In both: 1.Severe manifestations of the condition. 2.Altered thermoregulation. 3.Altered level of consciousness. In both: 1.Severe manifestations of the condition. 2.Altered thermoregulation. 3.Altered level of consciousness. Mexoedema Coma and Thyroid Storm

31. Watch respiration and maintain ABC Slow heating In ICU with cardiac monitor In severely ill: Give T4: 50 μg IV Q 8 hours for 24 hours. Then, 75 – 100 μg IV daily till oral intake. Hydrocortisone 50 mg IV Q8 hours. Watch respiration and maintain ABC Slow heating In ICU with cardiac monitor In severely ill: Give T4: 50 μg IV Q 8 hours for 24 hours. Then, 75 – 100 μg IV daily till oral intake. Hydrocortisone 50 mg IV Q8 hours. Mexoedema Coma

32. Admit to ICU PT u 300 mg PO Q 4 hours Inhibits periph. Generation of T3 from T4 Iodide: SSKI 1-2 drops PO Q 12 hours to inhibit thyroid hormone secretion rapidly. I – is given 2 hours post PT u to prevent synthesis of additional thyroid hormones from the I dose. Admit to ICU PT u 300 mg PO Q 4 hours Inhibits periph. Generation of T3 from T4 Iodide: SSKI 1-2 drops PO Q 12 hours to inhibit thyroid hormone secretion rapidly. I – is given 2 hours post PT u to prevent synthesis of additional thyroid hormones from the I dose. Thyroid Storm

33. Dexamethasone 2 mg Q 6 hours IV to prevent the release of hormones from gland & prevent generation of T3 from T4 in periphery. Propranolol 40 mg P.O. Q 6 hours, if not in cardiac failure. IV fluids Call slowly; paracetamol Avoid salicylates:- compete for binding of T3 and T4 by TBG, and large doses  ↑ metabolic rate Dexamethasone 2 mg Q 6 hours IV to prevent the release of hormones from gland & prevent generation of T3 from T4 in periphery. Propranolol 40 mg P.O. Q 6 hours, if not in cardiac failure. IV fluids Call slowly; paracetamol Avoid salicylates:- compete for binding of T3 and T4 by TBG, and large doses  ↑ metabolic rate Thyroid Storm (cont.)