Emergency endocrinology

Question 1

What are some causes of Addison’s (primary adrenal insufficiency)?

Answer 1

Autoimmune destruction
Adrenal glands removed surgically
Adrenal gland trauma
TB
Haemorrhage
Infarction
Cancer

Question 2

What are some causes of secondary adrenal insufficiency?

Answer 2

Congenital disorders
Fracture of the base of skull
Pit or hypothalamic surgery
Infiltration or infection of brain
Def of CRH

Question 3

What are the CF of Addison’s disease?

Answer 3

Reduced cortisol and aldosterone:
- Fatigue
- Muscle weak and cramps
- Dizzy - postural hypotension
- Thirst and craving salt
- Weight loss
- Abdo pain
- Depresison
- Reduced libido
- Bronze hyperpigmentation esp in skin creass

Question 4

What are the CF of Addisonian crisis?

Answer 4

Reduced conc/coma
Hypotension
Hypoglycaemia
Hyponatraemia and hyperkalaemia
N+V, abdo pain

Question 5

What are the ix in adrenal insufficiency?

Answer 5

Bloods - Na low, K high, BM low, cortisol low, ACTH high in primary, renin high in primary, aldosterone low

Short synacthen test

Question 6

What is the short synacthen test?

Answer 6

ACTH stim test
Give synthetic ACTH
Cortisol checked at 0mins, 30 mins and 60 mins
A failure of cortisol to double = Addison’s disease

Question 7

What is the management of Addisonian crisis?

Answer 7

AtoE
Fluid resus
100 mg IV hydrocortisone STAT, then infusion
IV dextrose if hypoglycaemic
Monitor electrolytes
Oral steroids after 3 days

Question 8

What is the maintenance management of Addison’s?

Answer 8

Hydrocortisone for cortisol
Fludrocortisone for aldosterone
Steroid card, ID tag and emergency letter
Doses are doubled during acute illness - sick day rules
Have a STAT dose of hydrocortisone IM

Question 9

What are some complications of Addisonian crisis?

Answer 9

Hypotension
V+D
Dehydration
Shock
Coma
Death

Question 10

What is the triad of DKA?

Answer 10

1. Hyperglycaemia - >11mmol
2. Blood ketones >3mmol
3. Acidosis - pH <7.35

Question 11

What are some causes of DKA?

Answer 11

First presentation of T1DM
Acute illness - infection, dehydration
Not taking insulin

Question 12

What are the CF of DKA?

Answer 12

N+V, abdo pain
Hypotension
Acetone breath
Reduced conc
Kussmaul breathing
Polyuria, polydipsia, weight loss

Question 13

What are some DKA mimics?

Answer 13

Alcoholic ketoacidosis
Starvation ketosis
Lactic acidosis
HHS

Question 14

What are the ix into DKA?

Answer 14

BM >11mmol/l
Blood ketones >3 mmol/l
U+E
ABG
ECG
Cultures if worried about infection

Question 15

What are the principles of treating DKA?

Answer 15

1. IV fluids - 0.9% NaCl 1L bolus then bags continuously, getting slower every time
2. Replace K, after first bolus can start to give K
3. Insulin fixed rate infusion
   Once <14mmol/L can add in glucose

Question 16

When is DKA resolved?

Answer 16

pH >7.35
Ketones < 0.6 mmol
Bicarb >15

Question 17

What are some complications of DKA?

Answer 17

Cerebral oedema !!! = suspect if pt rapidly deteriorating
More common in paeds
Involve senior

Question 18

What is HHS?

Answer 18

Hyperosmolar hyperglycaemic sate
- Hyperglycamia, severe >30mmol
- Hypotension
- Hyperosmolality = >320 mosmol/kg
- No significant ketosis or acidosis
- Normally in T2DM

Question 19

What are the main causes of HHS?

Answer 19

Infection
Medications that cause fluid loss ??
Surgery
Impaired renal func

Question 20

What are the CF of HHS?

Answer 20

N+V
Lethargy
Weakness
Confusion
Dehydration
Coma
Seizure

Question 21

What is the management of HHS?

Answer 21

1. FLuid resus
2. Insulin but only if ketones >1mmol or glucose fails to fall
3. VTE prophylaxis

Question 22

What are some RF of hypoglycaemia?

Answer 22

Drugs
Acute liver failure
Sepsis
Adrenal insuff
Alcoholism

Question 23

What are some of the hypoglycaemic drugs?

Answer 23

Insulin
SUs
GLP-1
DPP-4

Question 24

What are the CF of hypoglycaemia?

Answer 24

Shaking
Sweating
Palpitations
Hunger
Difficulty conc
Slurred speech
Confusion and irritability

Question 25

What is the management of hypoglycaemia when pt conc?

Answer 25

AtoE Glucose gel or tablet Sweets, fizzy pop

Question 26

What is the management of hypoglycaemia where the pt is unconc?

Answer 26

AtoE 75ml 10% dextrose IV over 15mins 1mg glucagon IM if not IV access Manage seizures

Question 27

What is a myxoedema coma?

Answer 27

Severe decompensated hypothyroidism - severe and life threatening - Hypothermia - Decreased mental status - Systemic manifestations of severe hypothyroidism

Question 28

What are some causes of myxoedema coma?

Answer 28

Severe/untreated hypothroidism Infection MI Stroke Trauma HF Drugs Cold temps

Question 29

What are the CF of myxoedema coma?

Answer 29

Lethargy or coma Hypothermai <35degrees Hypoventilation leading to resp failure Bradycardia and hypotension Hypoglycaemia Hyponatraemia Myxoedema - swelling??*8

Question 30

What are the ix into myxoedema coma?

Answer 30

Raised TSH and low T4 FBC to see in infection U+Es BM ABG - hypoventilation and resp failure

Question 31

What is the management of myxoedema coma?

Answer 31

1. ITU 2. IV T3/T4 3. 50-100mg IV hydrocortisone 4. Mechanical ventilation and O2 if hypoventilation 5. IV fluids 6. Correction of hypothermia 7. Correction of hypoglycaemia 8. Treat HF

Question 32

What are the CF of pheochromocytoma?

Answer 32

HTN Anxiety Weight loss Fatigue Palpitations Sweating, headaches, flushing, fever Dyspnea Abdo pain

Question 33

What is o/e in pheochromocytoma?

Answer 33

HTN Postural hypotension Tremor HTN retinopathy

Question 34

What are the ix into pheochromocytoma?

Answer 34

Raised catecholamine - plasma and urine Adrenal imaging CT CAP

Question 35

What is the management of peochromocytoma?

Answer 35

A blockers w phenoxybenzamine to prevent HTN crisis B blocker added if needed but only secondary to a blocker

Question 36

What is thyrotoxic storm?

Answer 36

Hyperthyroidism (rare) complication but is life threatening, too much T3/T4

Question 37

What are the CF of hyperthyroidism?

Answer 37

Tachycardia Fever Alt mental status Sweating Tremor N+V

Question 38

What are the ix into thyrotoxic storm?

Answer 38

TFTs Cardiac monitoring Sepsis 6

Question 39

What is the management of thyrotoxic storm?

Answer 39

1. IV propanolol - control sx 2. Propylthiouracil to reduce thyroid activity, IV hydrocortisone 3. Treat complications eg. hyperthermia, HF