Acue endocrine

Question 1

DKA presentation

Answer 1

Abdominal pain, confusion, fainting, shock

Question 2

ABCDE in DKA

Answer 2

A normal
B
* Kussmal breathing: short and shallow (RR high)
* SpO2 may be normal
* Ketotic breath
* Clear lungs (other than if chest infection precipitating DKA)

C
* CRT high, high HR, low BP
* ECG: for hyperkalaemia (hypo after tx)
* 2x LB cannulae: VBG [pH, Lact, HCO3], FBC, U&E, Glucose, Amylase, Cardiac enzymes?

D
* Capillary Blood glucose (high!) do Ketones!
* AVPU, GCS, pupillary reflexes.

Question 3

Management of DKA

Answer 3

First, give 1L bag of 0.9% NaCl [+40mmol KCL if K<3.2]

Then insulin 0.15u/kg bolus

Then insulin infusion 0.1u/kg/hr WITH 0.9% NaCl [+/-K]

Electrolyte monitoring (2-hourly) and cardiac monitoring (contrinuous)

Fluids switched to Glucose when CBG<14mmol/L (with insulin)

Stop when ketones <0.3 (unless new diagnosis, in which case continue until patient has had three meals to facilitate insulin req calculation)

CONTINUE long acting insulin

Question 4

DDx collapse/fainting/tiredness

Answer 4

Collapse DDX: (SY)NCOPE-MMT
* Neurological – Ischaemic, inflammatory, neoplasm, epilepsy.
* Cardiological – MI, arrhythmia, valvulopathy, Stokes-Adams
* Orthostatic/hypovolaemic – Internal bleed, fluid depletion (drugs/dehydrated)
* Pulmonary embolism
* Ectopic pregnancy
* Metabolic – Addison’s, DKA, hypoglycaemia, HONK
* Musculoskeletal – pain, fracture, rupture of tendon etc
* Toxins: poisoning

Question 5

Addison’s red flags

Answer 5

History of adrenal failure or long term steroid use, concurrent illness (without steroid dose increase); other AI history, female, hypothyroid, TB. Skin pigmentation

Question 6

ABCDE in Addison’s

Answer 6

A
* Patent; may be obstructed if severely low GCS.
* Arrest: CARDIAC ARREST AS PER ALS MANAGEMENT.

B
* RR and SpO2
* Should be normal

C
* ECG: may show signs of hyperkalaemia (tented T, long QRS, bradycardia, slurred ST, flat P.) [–>correct 10@10% CaGlu; 50@50% Dex; 10U insulin]
* BP low [correct –> 0.9%NaCl bolus]
* 2x IV cannulae; VBG, FBC, U&E, LFT, lipids and glucose

D
* CBG: glucose low [–> correct]

E
* Urine dip, CXR (seek cause to treat, often infection)

Question 7

Management of addisonian crisis

Answer 7

Dexamethasone 4mg IV OD for 3-4d
(or hydrocort 100mg IV TDS for 3d) / IM if unable to get access and/or patient has supply

+ saline for volume replacement
+ glucose if hypoglycaemic taking care not to worsen hypoNa

Seek cause (i.e. infection) and treat

Question 8

Hyperkalaemia management

Answer 8

• 10ml 10% Ca Gluconate (if there are ECG changes) - Stabilizes myocardium
• 50ml 50% dextrose+ 10u insulin- Drives K into cells
• Nebulized salbutamol
• Treat cause

Question 9

Causes of hyperkalaemia

Answer 9

1. Reduced GFR > renal failure
2. Reduced renin levels > T4RTA, NSAIDS
3. Reduced ATII > ACEi
4. Low ATII action > ARBs
5. Low adrenal function > Addisons disease (TB, AI), adrenal hypoplasia
6. Low Aldosterone effects > MRA
7. Normal cycle, but too much K released from cells > Rhabdomyolysis, Acidosis