Chemicals Flashcards
what is an important practical consideration when investigating Adisonian crisis?
the serum ACTH must be sent on ice and analyzed immediately by the lab
call ahead to the lab and porters to arrange prompt transfer
what should an FY1 do if faced with myxoedema coma?
patient must be manged on ITU
take blood and gain IV access.
bloods = glucose, TFT, FBC, U&E, blood cultures
going to have to start treatment with liothyronine (T3) and hydrocortisone infusions (check BNF)
consider whether the cause is thyroid (scars, PTU/carbimazole, radioiodine) or pituitary (low TSH)
what is the typical fluid deficit in adult patients with DKA?
0.1 L/kg…
so 70 kg patient = 7 L fluid deficit
what is the role of FY1 in phaeochromocytoma crisis?
patient needs to be managed on ITU with endo support
principle is alpha- then beta- blockade
phentolamine 2-5 mg IV
followed by phenoxybenzamine 10 mg/24 hours
what is the immediate management of hypopituitary coma?
delay can lead to loss of life!
100 mg hydrocortisone over 6 hours
CALL ENDO REG
will eventually consider liothyronine or pituitary surgery
managing HONK/HHS
onset is slower and deficit is greater (8-15 L in 70 kg adult)
no ketonaemia or acidosis. no insulin needed.
start 0.9% saline resus over 48 hours
VTE prophylaxis with LMWH (important)
keep blood glucose 10-15 mmol/L to avoid cerebral oedema
replace K+ as for DKA protocol
call for endo reg review once fluids are running
what are the complications of DKA?
cerebral oedema
hypoK+, hypMg++, hypophosphataemia
aspiration pneumonia
VTE
what is the medication called that acts as active T3 used in myxoedema coma?
liothyronine
when do you add K+ to your fuild replacement in DKA?
judge by the last available VBG
do not add K+ to the first bag of fluid
>5.5 - do not add
3.5-5.5 - 40 mmol/bag
<3.5 - seek ITU/HDU input
what are the indicators of severe DKA?
ketones, bicarb, pH, K+, GCS, sats, SBP, HR, AG
- ketones >6
- venous bicarb <5
- pH <7.0
- K <3.5 mmol/L
- GCS <12
- SpO2 <92%
- SBP <90
- HR >100 or <60 bpm
- anion gap >16
what are the ketones present in the blood during ketoacidosis?
beta-hydroxybutarate
acetoacetate
what must you consider with ++ ketones on dipstick?
this does not equal ketonaemia!
anyone will have up to ++ ketones on dipstick after overnight fast
confirm findings with venous blood ketones
what about an elevated serum amylase in DKA?
amylase can be elevated in DKA, up to 10x upper limit of normal
there will likely be non-specific abdominal pain as well
this has a low specificity for pancreatitis, so any diagnosis must be supported by other tests
managing DKA
-
fluids
- 1L normal saline over 1 hour
- if SBP <90, 500 mL NaCl over 15 mins. repeat. if continuting circulatory failure then escalate to ITU
- relevant investigations, DKA proforma, call for senior review
-
insulin
- 50U Actrapid in 50 mL normal saline
- run at 0.1 U/kg/hr
- aim for a decrease in blood ketones of 0.5 mmol/L/hr
- increase by up to 1 U/hr if not getting adequate response
-
monitoring
- check CBG/CBK every hour
- check VBG every 2 hours until 24 hours
- catheterisation, aim for UO > 0.5 mL/kg/hr
-
avoid hypos
- add 10% dextrose at 125 mL/hr along side the saline once blood glucose <14 mmol/L
-
When to stop?
- blood ketones <0.6 mmol/L
- pH >7.3
- bicarbonate >15.0 mmol/L
managing a hypo
can be managed by FY1, should have nursing input, fill out the diabetic glucose monitoring sheets accurately, including the treatment given
conscious, oriented, safe swallow, cooperative - 200 mL juice
conscious, uncooperative - glucogel between gums and cheek
unconscious/rousable - 10% glucose IVI, 200 mL/hr
really unconscious - 10% glucose IVI, 200 mL/15 mins
unresponsive still.. glucagon 1mg IV/IM, call for senior review
