Endocrine emergencies

1. Endocrine
Emergencies
HANNAH KNAUSENBERGER
SCGH ED | JUNE 2016

2. Most common
Diabetic emergencies / glucose
Adrenal crisis
Thyroid storm
Parathyroid-related hypocalcaemia
Pheochromocytoma
Pituitary apoplexy
DKA, HHK (HONK), Hypoglycaemia
Diabetic emergencies
are by far the most
common presentation.

3. The amazing endocrine system..

4. Case
37yo female
Found by family on the floor - last seen 2 days prior
GCS 10
BSL 'hi'
Cold to touch
PMHx - T1DM on humalog and novorapid (?doses)
- IVDU
- Previous admissions with hypoglycaemia

5. Case
On arrival: Agitated, combative
A- Patent
B - RR 20, Sats 100% RA, Chest clear
C - HR 80, BP 100/70, cool peripheries, HS dual no
murmur
D - GCS 10 (E3V2M5), PEARL, BSL 39
E - Temp 31.9
Secondary survey: No evidence head injury, abdo soft,
multiple bruises to legs, track marks to ACF bilat
Ketones 5

6. ABG
pH 6.8
pCO2 8
pO2 172
HCO3 1
BE ***
AG 31
Na 140
K 4.8
Cl 113
Ca 1.35
Lac 3
Glu 36
Creat 91
Hb 126
Diagnosis ?
Differentials?

7. DKA
Hyperglycaemia + Ketosis + academia
Hyperosmolality and HAGMA on gas
Usually evolves quickly (24h)
How? Insulin deficiency causes the body to break down AA's and TG's
instead of carbohydrates for energy. Counter-regulatory glucagon ++
release causes unrestrained lipolysis and generates ketones.
Triggers: infection, MI, trauma, drugs (eg. cocaine,steroids), non-
compliance
Differentials: alcoholic/fasting ketoacidosis, other causes of HAGMA
(lactic acidosis, aspirin, methanol, etc.. )
BSL >11mmol/L (or known diabetes)
Bicarb <18mmol/L and/or venous pH <7.35
Ketones => 3mmol/L

8. NEW PROTOCOL (FSH) on scghed.com
Polyuria
Polydipsia
Vomiting
Abdominal pain
Dehydration
Tachypnoea
Sweet breath
Kussmaul Breathing
Altered mental state
Lethargy
Coma
DEATH

9. Case Cont.
Goal is to correct ketonaemia (and therefore the acidosis)
Once Ketones are cleared <0.6, insulin can be changed to S/C
WATCH OUT FOR:
Hypoglycaemia, Hypo/Hyperkalaemia, Cerebral Oedema, Pulmonary oedema
Second IV access
Bear hugger
IVH
Insulin - 50U in 500ml N.Saline at 40ml/H = 4U/hr
Arterial Line
Potassium replacement
CT Head
ICU admission

12. Hyperosmolar Hyperglycaemic State
(HHS - or HONK)
Insulin deficiency, prolonged high BSL causing severe dehydration, increased
osmolality, coma and death.
Often in the elderly or undiagnosed diabetes
Hypovolaemia, hyperglycaemia (>30), high serum osmolality (>320 mosmol/kg)

13. Hyperosmolar Hyperglycaemic State
(HHS - or HONK)
Insulin deficiency, prolonged high BSL causing severe dehydration, increased osmolality,
coma and death.
Often in the elderly or undiagnosed diabetes
Hypovolaemia, hyperglycaemia (>30), high serum osmolality (>320 mosmol/kg)
Hypokalaemia
TRIGGERS - Infection, acute medical issues, non-compliance
Presents similarly to DKA but often with a longer history (several days); also
neurologic symptoms are more common
WHAT SHOULD I DO?
Hyperglycaemia is treated with IVH initially, not insulin; this is added later
HHS PROTOCOL
scghed.com
ICU admission if:
unstable
anuric
low GCS
severely deranged Na/Osmol/Glu

14. Hyperosmolar Hyperglycaemic State
(HHS - or HONK)

15. Hyperosmolar Hyperglycaemic State
(HHS - or HONK)

17. Diaphoretic
Anxious
Palpitations & tachycardia,
Tremor
Confused with slurred speech
Blurry vision
SEIZURE...

18. HYPOGLYCAEMIA
TRIGGERS - insulin / alcohol / salicylate / other drugs (b-
blockers) / tumours (insulinoma) / liver dysfunction / adrenal
insufficiency / myxoedema
If conscious, treat PO
If not - 50ml 50% IV Dextrose / Glucagon 1mg IM / IV 10%
Dextrose

20. ADRENAL CRISIS
Mineralocorticoid deficiency --> Na loss, K high, dehydration, acidosis,
hypotension
Glucocorticoid deficiency --> hypoglycaemia, weakness, hyperpigmentation,
reduced resistance to infection & stress
Acute insufficiency in Addison's disease
Addison's = Adrenal destruction (Autoimmune, tumour,
adrenal TB, mets, haemorrhage) or drugs (rifampicin) or hypopituitarism
This causes:
Profound weakness, N&V, severe pain, HYPOTENSION, renal failure,
hypoglycaemia, pigmentation, extremes of temperature
crisis

21. ADRENAL CRISIS
Mineralocorticoid deficiency -->
Na loss, K high, dehydration,
acidosis, hypotension
Glucocorticoid deficiency -->
hypoglycaemia, weakness,
hyperpigmentation, reduced
resistance to infection & stress
Acute insufficiency in Addison's disease
Addison's = Adrenal destruction (Autoimmune, tumour,
adrenal TB, mets, haemorrhage) or drugs (rifampicin) or hypopituitarism
This causes:

22. Adrenal crisis
Management:
IV fluids, steroids, dextrose, evaluate cause (antibodies, adrenal imaging / CT )
Hyponatraemia (90%)
Hyperkalaemia (65%)
VBG: hypoglycaemia, high urea, anaemia, metabolic acidosis
crisis
Profound weakness, N&V, severe pain, HYPOTENSION, renal failure,
hypoglycaemia, pigmentation, extremes of temperature

24. THYROID STORM
A rare, life-threatening condition with severe clinical manifestations of
thyrotoxicosis.
Risk factors - untreated hyperthyroidism; surgery, trauma, infection; irregular use
of antithyroid drugs
Lab findings: Low TSH / High T4 and/or T3.
Hyperglycaemia secondary to catecholamine-induced inhibition of insulin release .
SYMPTOMS:
Hyperpyrexia, cardiovascular dysfunction, altered mental state, AF
WHAT SHOULD I DO?
b-blocker to control sx and reduce adrenergic tone
thionamide to block new hormone synthesis (eg. propylthiouracil PTU)
Iodine solution to block release of thyroid hormone
Glucocorticoids to reduce T4-T3 conversion
There are no universal guidelines for diagnosis.
The degree of hyperthyroidism is NOT a diagnostic criterion.

25. PTH related hypocalcaemia
hypoparathyroidism (AI, surgical, radiation, lesion)
magnesium deficiency (needed for PTH secretion)
failure of Ca release (osteomalacia, renal failure, hungry bone syndrome)
Calcium loss (blood transfusions, pancreatitis)
Failure of PTH or inability to release Ca from bone
Causes:
FEATURES: cramps, tingling esp. fingers & lips, carpopedal spasm, tetanic
contractions, seizure, hypotension, bradycardia, arrhythmia, CCF
WHAT SHOULD I DO? Urgent IV calcium gluconate, followed by infusion

27. Acute infarction of the pituitary due to ischaemia or haemorrhage (trauma,
radiation, anticoagulants)
Symptoms: Headaches, N&V, visual disturbance, meningism
Diagnosis: CT / history / visual field defect
WHAT SHOULD I DO? stabilise (ABC), hydrocortisone, fluid balance, neurosurg
PITUITARY APOPLEXY
PHAEOCHROMOCYTOMA
Catecholamine-secreting tumour of the adrenal medulla
Can cause HYPERTENSIVE EMERGENCIES
10% bilateral, male = female, mostly in adrenal medulla, <10% malignant
SECRETE: adrenaline, noradrenaline, dopamine
Symptoms: HTN, anxiety, panic, sweating, palpitations, flushing/pallor, headache,
pyrexia, tachycardia, arrhythmia
Diagnosis: check BSL, check K, urinary catecholamines, CT abdomen
WHAT SHOULD I DO? Rehydration, alpha blockade (phentolamine), then b-blockade,
surgical resection

28. SUMMARY
MOST ENDOCRINE EMERGENCIES relate to hypo/hyperglycaemia.
The remainder are rare.
KNOW WHERE TO FIND PROTOCOLS
Consider the diagnosis and the triggers
Don't delay treatment
SOURCES:
UpToDate
scghed.com
Slideshare "Endocrine Emergencies" (V. Chan 2011)
doctorportal.com
pixabay
Dr.James Wheeler