EndocrineEndocrine EmergenciesEmergencies

Name a Few…Name a Few…

DKADKA HONK (HHOS)HONK (HHOS) Addisonian crisisAddisonian crisis Thyroid stormThyroid storm Myxoedemic comaMyxoedemic coma

What’s the Diagnosis?What’s the Diagnosis? 83yr woman with 3/7 histroy of malaise and 83yr woman with 3/7 histroy of malaise and

polyuria. PMH type I DM and HTNpolyuria. PMH type I DM and HTN HR 100, BP 100/60, GCS 14, SaO2 100% on high HR 100, BP 100/60, GCS 14, SaO2 100% on high

flow O2flow O2 Na 125Na 125 K 6.0K 6.0 Cl 81Cl 81 HCO3 7HCO3 7 Ur 25Ur 25 Cr 262Cr 262 Glu 54.5Glu 54.5 Osmolality 337Osmolality 337

DKADKA DefinitionDefinition

– BSL BSL increasedincreased– Ketones Ketones presentpresent– Anion gap Anion gap >10>10– HCO3 HCO3 <15<15– pH pH <7.3<7.3

Mortality 5-15% (less in children)Mortality 5-15% (less in children) BewareBeware if pregnantif pregnant:: 30-50% mortality 30-50% mortality

All About KetonesAll About Ketones Beta-hydroxybutyrateBeta-hydroxybutyrate

– Detected by Detected by Medisense Medisense bloodblood test test– Higher in alcoholic ketoacidosis than Higher in alcoholic ketoacidosis than

in DKAin DKA

AcetoacetateAcetoacetate– >6x the levels of above AFTER >6x the levels of above AFTER

conversion (ie. May initially be conversion (ie. May initially be negative)negative)

– measured by measured by Ketostix Ketostix urineurine test test

Acetone Acetone – Detected on Detected on AcetestAcetest– Responsible for ketotic breathResponsible for ketotic breath

How do ketones impact on How do ketones impact on management?management?– Endpoint = ketones cleared, normal Endpoint = ketones cleared, normal

anion gapanion gap

Other Vital StuffOther Vital Stuff– VBG VBG Anion gap metabolic acidosisAnion gap metabolic acidosis

Maybe metabolic alkalosis (vomiting), resp alkalosis (hyperventilation)Maybe metabolic alkalosis (vomiting), resp alkalosis (hyperventilation)

– BSLBSL How does BSL impact on management?How does BSL impact on management? Aim decr no more than 5/hrAim decr no more than 5/hr

– Na…Na… How do I calculate corrected Na???? How do I calculate corrected Na???? Average deficit 5-10mmol/kgAverage deficit 5-10mmol/kg

Na + ( (Glu – 5.5) / 3 )Na + ( (Glu – 5.5) / 3 ) So if Na is 128 and Glu is 65 – what is real Na?So if Na is 128 and Glu is 65 – what is real Na?

How does Na impact on management?How does Na impact on management?

– K… K… How do I correct K for pH???? How do I correct K for pH???? Average deficit 3-5mmol/kgAverage deficit 3-5mmol/kg

Decr pH by 0.1 = Incr K by 0.5Decr pH by 0.1 = Incr K by 0.5 So if pH is 7 and K is 5.7 – what is real K?So if pH is 7 and K is 5.7 – what is real K?

How does K impact on management?How does K impact on management?

– Osmolality… Osmolality… How do I calculate osmolality? How do I calculate osmolality? Average body H20 deficit 100ml/kg Average body H20 deficit 100ml/kg Do I even have to? Can’t I just measure it?? Do I even have to? Can’t I just measure it?? (ie. 10% dehydration)(ie. 10% dehydration)

(2 x Na) + Glucose + Urea(2 x Na) + Glucose + Urea

How does osmolality impact on management?How does osmolality impact on management?– Aim decr by no more than 1-2/hrAim decr by no more than 1-2/hr

Any other investigations?Any other investigations?– ?precipitant; ?ARF; ?level of long-term control?precipitant; ?ARF; ?level of long-term control

Let’s look at that gas again…Let’s look at that gas again…

Na 125Na 125 K 6.0K 6.0 Cl 81Cl 81 HCO3 7HCO3 7 Ur 25Ur 25 Cr 262Cr 262 Glu 54.5Glu 54.5 Osmolality 337Osmolality 337

Management of DKAManagement of DKA

It’s bloody confusing and hard to It’s bloody confusing and hard to rememberremember

Split into…Split into…

1) IV fluids1) IV fluids2) Potassium2) Potassium3) Insulin3) Insulin4) NaHCO34) NaHCO3

FluidsFluids Adult ChildAdult Child

1L stat1L stat 10-20ml/kg bolus10-20ml/kg bolus rpt until haemodynamically stablerpt until haemodynamically stable

1L over 1hr Replace deficit over 48hrs1L over 1hr Replace deficit over 48hrs 1L over 2hrs 1L over 2hrs 1L over 4hrs Deficit = %dehydration x weight x 101L over 4hrs Deficit = %dehydration x weight x 10 1L over 10hrs1L over 10hrs

Use N salineUse N saline Use 0.45% saline Use 0.45% saline Use 0.45% saline Use 0.45% saline andand correct correct over 72hrsover 72hrs if Na >150 / Osm >320 if Na >150 / Osm >320if Na >150 / Osm >320 if Na >150 / Osm >320

Watch: Na, osmolality, BSLWatch: Na, osmolality, BSL

Change to Change to 0.45% saline + 5% dex0.45% saline + 5% dex when BSL <15when BSL <15 and also if…..and also if…..

BSL decreasing too fast (ie. >5/hr)BSL decreasing too fast (ie. >5/hr) BSL <10 but ketones ongoingBSL <10 but ketones ongoing

PotassiumPotassium

How do you correct for pH again?How do you correct for pH again? Only add K in 2Only add K in 2ndnd hour / once UO / K <5 hour / once UO / K <5

AdultAdult– K 4-5 = 10mmol/hrK 4-5 = 10mmol/hr– K 3-4 = 30mmol/hrK 3-4 = 30mmol/hr– K <3 = 40mmol/hrK <3 = 40mmol/hr

ChildChild– Add 40mmol to 1L bagAdd 40mmol to 1L bag

InsulinInsulin

Start after 1hr of fluids Start after 1hr of fluids if K >3.4 (otherwise if K >3.4 (otherwise replace K first)replace K first) Do you give a stat dose of actrapid?Do you give a stat dose of actrapid?

Actrapid infusionActrapid infusion– 0.1iu/kg/hr (max 6iu/hr)0.1iu/kg/hr (max 6iu/hr)– Decrease to 0.05iu/kg hr if….Decrease to 0.05iu/kg hr if….

BSL <12BSL <12 (stop for 15mins if still too low despite this) (stop for 15mins if still too low despite this) Aim for BSL decrease of no more than 5/hrAim for BSL decrease of no more than 5/hr K <3K <3

NaHCO3NaHCO3 What are the indications?What are the indications?

– pH <7pH <7– HCO3 <5HCO3 <5– Life threatening hyperkalaemiaLife threatening hyperkalaemia– ComaComa– Haemodynamic compromise Haemodynamic compromise unresponsive to IV fluidsunresponsive to IV fluids

What is the dose? What is the dose? – 0.5 – 2mmol/kg over 1-2hrs0.5 – 2mmol/kg over 1-2hrs

What is the endpoint? What is the endpoint? – pH >7.1pH >7.1– HCO3 >10HCO3 >10

What are the risks?What are the risks?– Worsened intracellular acidosis, hypokalaemia, hypernatraemia, Worsened intracellular acidosis, hypokalaemia, hypernatraemia,

osmolar shifts and cerebral oedema, volume overloadosmolar shifts and cerebral oedema, volume overload

Cerebral oedemaCerebral oedema 70% mortality; 10% have ongoing neuro 70% mortality; 10% have ongoing neuro

deficit; more common in childrendeficit; more common in children Onset 4-12hrs after starting trtOnset 4-12hrs after starting trt What are the symptoms?What are the symptoms?

– Headache, decr LOC, decr HR, incr BP, pupil Headache, decr LOC, decr HR, incr BP, pupil changes, seizure, urinary incontinencechanges, seizure, urinary incontinence

How do you treat it?How do you treat it?– Mannitol 0.5-1g/kgMannitol 0.5-1g/kg– 3% saline 5-10ml/kg over 30mins3% saline 5-10ml/kg over 30mins– Half maintenance fluidsHalf maintenance fluids

Hyperglycaemic Hyperosmolar StateHyperglycaemic Hyperosmolar State

DKADKA HHOSHHOSMortality up to 15%Mortality up to 15% Mortality up to 45%Mortality up to 45%

BSL +BSL + BSL ++++BSL ++++pH <7.3pH <7.3 pH >7.3pH >7.3

Anion gap >12Anion gap >12 Anion gap <12Anion gap <12

HCO3 <15HCO3 <15 HCO3 >15HCO3 >15

Ketones ++++Ketones ++++ Ketones -/+Ketones -/+

Maybe incr osmolalityMaybe incr osmolality Osmolality >320-350Osmolality >320-350

H20 deficit 100ml/kg (10% dehydration)H20 deficit 100ml/kg (10% dehydration) H20 deficit more (H20 deficit more (20-25% dehydration20-25% dehydration))

Higher Na + K deficitHigher Na + K deficit

Resus with N salineResus with N saline

Use N saline thereafter unless Na >150 / Osm Use N saline thereafter unless Na >150 / Osm >320>320

Use 0.45% saline thereafterUse 0.45% saline thereafter (unless low (unless low corrected Na)corrected Na)

Change to 0.45% saline + 5% dex when BSL <15Change to 0.45% saline + 5% dex when BSL <15

Replace deficit over 48hrsReplace deficit over 48hrs Replace deficit over 48-72hrsReplace deficit over 48-72hrs

Similar K replacementSimilar K replacement

Actrapid 0.1iu/kg/hr (max 6iu/hr)Actrapid 0.1iu/kg/hr (max 6iu/hr) Actrapid Actrapid 0.050.05iu/kg/hriu/kg/hr (max 3iu/hr) (max 3iu/hr)

Heparin important (hypercoag state)Heparin important (hypercoag state)

What’s the diagnosis (bearing in What’s the diagnosis (bearing in mind this is an endocrine talk)?mind this is an endocrine talk)?

An 85 year old man is brought to your Emergency Department fitting. His 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 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 has a PMH of polymyalgia rheumatica. These are his initial biochemistry results.results.

Na 99 mmol/L Na 99 mmol/L K 5.9 mmol/LK 5.9 mmol/L Cl 68 mmol/L Cl 68 mmol/L BSL 2.2mmol/LBSL 2.2mmol/L HCO3 - 21 mmol/L HCO3 - 21 mmol/L Urea 10.1 mmol/L Urea 10.1 mmol/L Cr 180 umol/L Cr 180 umol/L pH 7.1 pH 7.1 Anion gap normalAnion gap normal pCO2 31 mmHg pCO2 31 mmHg pO2 149.5 mmHg pO2 149.5 mmHg BE 2.4BE 2.4 HCO3 17.6 mmol/LHCO3 17.6 mmol/L

Addisonian CrisisAddisonian Crisis

Back to Part One’s!!Back to Part One’s!!

Effects of cortisol Effects of cortisol – Incr BSL (gluconeogenesis, lipolysis, decr ketogenesis, decr insulin release)Incr BSL (gluconeogenesis, lipolysis, decr ketogenesis, decr insulin release)

Effects of aldosteroneEffects of aldosterone– Incr Na (incr reabsorption)Incr Na (incr reabsorption)– Decr K (incr excretion in DCT)Decr K (incr excretion in DCT)– Alkalosis (incr H excretion)Alkalosis (incr H excretion)

So…. what changes may be seen on bloods in view of the above?So…. what changes may be seen on bloods in view of the above?– Dehydration – Dehydration – fluid resistant hypotensionfluid resistant hypotension– Decr osmolalityDecr osmolality– Decr BSLDecr BSL– Decr Na, ClDecr Na, Cl– Incr KIncr K– Non-anion gap metabolic acidosisNon-anion gap metabolic acidosis

– If 2Y hypoadrenalism patient euvolaemic with lower K, as aldosterone is still If 2Y hypoadrenalism patient euvolaemic with lower K, as aldosterone is still workingworking

Recognising Addisonian CrisisRecognising Addisonian Crisis Who gets it?Who gets it?

– 1Y1Y Long-term steroids stopped abruptlyLong-term steroids stopped abruptly Adrenal haemorrhage (neonates, anticoagulated folk, sepsis (Adrenal haemorrhage (neonates, anticoagulated folk, sepsis (name the name the

syndromesyndrome), trauma)), trauma) Addison’s diseaseAddison’s disease Prior surgical removalPrior surgical removal Adrenal destruction due to other cause: infection (eg. TB, HIV, CMV), Adrenal destruction due to other cause: infection (eg. TB, HIV, CMV),

thrombosis, metastatic Cathrombosis, metastatic Ca– 2Y2Y

Head traumaHead trauma MeningitisMeningitis In pregnancy (In pregnancy (name the syndromename the syndrome).). Pituiary failurePituiary failure

How do they present? How do they present? – Hypotension, lethargy, weight loss, Hypotension, lethargy, weight loss, weakness, N+V, abdo pain, diarrhoeaweakness, N+V, abdo pain, diarrhoea– Ie. Non-specifically unwell and not responding Ie. Non-specifically unwell and not responding to conventional treatment plus characteristic to conventional treatment plus characteristic electrolyte changeselectrolyte changes

ManagementManagement InvestigationInvestigation

– Name the investigationName the investigation

ManagementManagement– IV fluids ++++ (vasopressors may be IV fluids ++++ (vasopressors may be

needed)needed)– DextroseDextrose– Treat K if neededTreat K if needed– Dexamethasone 10mg IV stat (give initially Dexamethasone 10mg IV stat (give initially

as doesn’t interfere with investigations)as doesn’t interfere with investigations)– ……then hydrocortisone 250mg IV statthen hydrocortisone 250mg IV stat

What’s the diagnosis?What’s the diagnosis?

17yr old female presents feeling anxious, 17yr old female presents feeling anxious, unwell, tremulous, hyperventilating, unwell, tremulous, hyperventilating, looking flushed. Recent history of looking flushed. Recent history of abdominal pain and diarrhoea. abdominal pain and diarrhoea.

HR 130, T 38, BP 140/87, RR 24HR 130, T 38, BP 140/87, RR 24 On examination: gallop rhythm, bibasal On examination: gallop rhythm, bibasal

crepitations, abdomen SNTcrepitations, abdomen SNT pHpH 7.87.8 PCO2PCO2 15 mmHg15 mmHg PO2PO2 192 mmHg192 mmHg (75-100)(75-100)

Thyroid CalamitiesThyroid Calamities

Back to Part Back to Part

One’s again!One’s again!

Effect of T3+4Effect of T3+4– Incr metabolismIncr metabolism– Incr GI motilityIncr GI motility– Incr glucose absorptionIncr glucose absorption– Incr sensitivity to epinephrine and Incr sensitivity to epinephrine and

norepinephrine, increased beta-receptorsnorepinephrine, increased beta-receptors

Thyroid StormThyroid Storm

Clinical diagnosis – labs don’t differentiateClinical diagnosis – labs don’t differentiate Mortality 10% treated, 90% untreated with Mortality 10% treated, 90% untreated with

death due to CV collapsedeath due to CV collapse

Who gets it?Who gets it?– Undiagnosed GravesUndiagnosed Graves– Meds – XS thyroxine / withdrawal from anti-Meds – XS thyroxine / withdrawal from anti-

thyroid drugs / iodine or contrastthyroid drugs / iodine or contrast– Stressor – MI, DKA, OTStressor – MI, DKA, OT

Recognising Thyroid StormRecognising Thyroid Storm

Diagnostic criteriaDiagnostic criteria– Fever >37.8Fever >37.8– Incr HRIncr HR out of proportion to fever (ie. >120) out of proportion to fever (ie. >120)– CNS disturbanceCNS disturbance (eg. Altered LOC, seizures) (eg. Altered LOC, seizures)

OtherOther– AP, N+V, diarrhoea, high output CCF (wide AP, N+V, diarrhoea, high output CCF (wide

pulse pressure, S3 gallop rhythm), HTN, pulse pressure, S3 gallop rhythm), HTN, dehydration, sweatingdehydration, sweating

Investigations – non-specificInvestigations – non-specific

ManagementManagement A + BA + B

– Give O2 as consumption increasedGive O2 as consumption increased CC

– IV fluids containing dextroseIV fluids containing dextrose– Cardioversion better than drugs for arrhythmiasCardioversion better than drugs for arrhythmias

Treat causeTreat cause

Definitive treatmentDefinitive treatment– Esmolol 250-500mcg/kg bolus Esmolol 250-500mcg/kg bolus infusion (safe as short half life; infusion (safe as short half life;

titratable; blocks cardiac and peripheral effects and slows conversion titratable; blocks cardiac and peripheral effects and slows conversion of T3 to T4)of T3 to T4)

– If less severe can use PO propanololIf less severe can use PO propanolol– Hydrocortisone 100mg IV (slows conversion of T3 to T4 and decreases Hydrocortisone 100mg IV (slows conversion of T3 to T4 and decreases

hormone release)hormone release)– Propylthiouracil / methimazole / iodidePropylthiouracil / methimazole / iodide

Supportive careSupportive care– Ongoing fluids, monitor electrolytes and BSL, treat feverOngoing fluids, monitor electrolytes and BSL, treat fever

What’s the Diagnosis? (This was What’s the Diagnosis? (This was an actual patient I saw last week)an actual patient I saw last week)

58yr old man with non-specific 58yr old man with non-specific malaisemalaise

PMH: hyperthyroidism treated with PMH: hyperthyroidism treated with radioactive iodine; known to be non-radioactive iodine; known to be non-compliant with treatmentcompliant with treatment

OE: normal observations; mild OE: normal observations; mild oedema around eyes; examination oedema around eyes; examination otherwise unremarkableotherwise unremarkable

Myxoedema ComaMyxoedema Coma Who’s ever seen one???Who’s ever seen one??? Mortality 50%; same triggers as thryoid stormMortality 50%; same triggers as thryoid storm SymptomsSymptoms

– A: hoarseness, glottic oedemaA: hoarseness, glottic oedema– B: decr RRB: decr RR– C: decr BP, CCFC: decr BP, CCF– D: decr LOC, hypothermia without shivering, seizuresD: decr LOC, hypothermia without shivering, seizures– E: hypoglycaemia, paralytic ileusE: hypoglycaemia, paralytic ileus

ManagementManagement– ABC, treat causeABC, treat cause– T3 has rapid effect, T4 has smoother improvement, give T3 has rapid effect, T4 has smoother improvement, give

hydrocortisonehydrocortisone– Monitor electrolytes esp Na and titrate fluids accordinglyMonitor electrolytes esp Na and titrate fluids accordingly– RewarmingRewarming

Anything else you want to talk Anything else you want to talk about…?about…?

Hyponatraemia?Hyponatraemia? Hypernatraemia?Hypernatraemia? Metabolic acidosis?Metabolic acidosis? Sodium bicarb use?Sodium bicarb use?