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Flashcards in Endocrine Deck (36):
1

Diagnosis of DKA

  • Glu >= 11.1
  • AG > 10
  • HCO3 < 15
  • pH < 7.3
  • moderate ketonuria/ketonemia

2

Rapid acting Insulins

 

Apidra/Humalog/NovoRapid

Onset: 10-15 min

Peak: 1-2 h

Duration: 3-4 h

3

Short-acting Insulins
 

Humulin-R/Toronto

Onset: 30 min

Peak: 2-3 h

Duration: 6h

4

Intermediate-acting Insulins


Humulin-N/NPH

Onset: 1-3 h

Peak: 5-8 h

Duration: Up to 18 h

 

5

Long-acting Insulins
Lantus
Levemir

Onset: 90 min

Peak: None

Duration: Lantus, 24h; Levemir 16-24h

6

Humulin 70/30

 

70% NPH

30% Humulin R

For Novolin, etc., higher number is NPH, lower is regular

 

Usually given BID with meals.

7

General dosing of insulin

0.5-1 unit/kg/day

50-75% given as long acting or intermediate, rest given preprandially

8

Target Organ Damage in HTN

Stroke

Dementia

Hypertensive Retinopathy

LVH

CAD

CKD

PAD

9

When & How to screen for renovascular HTN

>=2 of:

- sudden onset/worsesning at >55 or

- abdominal bruit

- HTN resistant to >=3 drugs

- Cr rise >=30% with ACE/ARB

- other atherosclerotic vascular disease

- recurrent pulmonary edema with HTN surges

Investigations: captopril-enhanced radioisotope renal scan (if eGFR >60), renal doppler, MRI, or CT angio.

10

When to screen for hyperaldosteronism?

- HTN with spontaneous hypo K (

- HTN with marked diuretic induced hypo K (

- HTN resistant to >=3 drugs

- HTN with incidental adrenal adenoma

11

When to screen for pheo

- paroxysmal or severe (>180/110) HTN refractory to usual therapy

- HA's, palps, sweating, panic attacks, pallor

- HTN triggered by BB's, MAOI's, micturition, changes in abdo pressure

- HTN with adrenal mass or HTN with MEN 2A/2B

12

Management of subclinical hypothyroidism

  • subclinical (increased TSH but normal FT4): pregnancy TSH >2.5, TPO Ab +ve, TSH >10,
  • monitor Q12 months, ~10%/year progress to clinical

13

Treatment of hypothyroidism

  • LT4 12.5-50 mcgs/day
  • Increase Q4-6 weeks
  • Males: 125-200 mcgs/day
  • Females: 75-122 mcgs/day
  • In young healthy patients, may start at full dose right away

14

Causes of Hyperthyroidism

  • Graves: 60-80%, antibodies against TSH receptor
  • TMNG: 5%, insiduous, >40 years old
  • Toxic adenoma: younger pts in iodine-deficient area
  • Thyroiditis
    • subacute: resolves in 8 months
    • lymphocytic + postpartum
  • treatment-induced: iodine, amio
  • tumour: metastatic thyroid cancer or ovarian cancer

15

Management of Thyroid Storm

  • sublinical: treat if TSH
  • betablockers: propranolol 10-40 mg, atenolol 25-100 mg, metoprolol 25-100 mg
  • methimazole: 5-120 mg for 12-18 months then taper, DC if asymptomatic + normal TSH
  • radioactive iodine
  • subtotal thyroidectomy: treatment of choice in pregnancy + young patients 

16

Labs for DKA

  • cap glucose, urine dip, ECG
  • CBC, GBCL, ext lytes, VBG, lactate, urinalysis, +- serum ketones
  • urine dip only detects AcAc, actually worsens with rehydration as bHB and AcAc in equilibrium and bHB favoured in low-flow states
  • then
    • ext lytes, VBG Q2-4h
    • CBG Q1h

17

DKA Fluids Adult

  • average adult deficit is 5-10 L
  • 1-2 L NS in first hour
  • then NS @ 250-500 mL/h (0.45% NS in hypernatremic/eunatremic patients)
  • generally 2L in 0-2h, 2L in 2-6h, 2L in 6-12 h
  • When glucose <14, change to D5W 0.45% NS

18

DKA Fluids Children

  • 5-10mL/kg NS boluses while hypotensive
  • then NS at 1.5x-2x maintenance

19

K+ Management, DKA

  • most adults need 100-200 mEq in first 24h
  • if <3.3, hold insulin,
  • if 3.3-5, give 10-20 mEq/h IV (then PO when tolerating)
  • >5, hold potassium
  • basically add 20-40 mEq/L to IVF for kids and adults when K+ <5.0 and peeing

20

DKA Insulin Management

  • after fluid bolus, or through second IV line, give regular insulin (e.g. Humulin R) at 0.1 unit/kg/h, once confirmed that K is >3.3
  • decrease drip rate once euglycemic and add D5W
  • target glucose 8.3-11
  • once eating, stop D5W
  • once gap closed, pH normal, bicarb > 18 and eating
    • 10 units Humulin R 30-60 minutes before stopping infusion
    • 80% of usual long-acting insulin 1-2 h before stopping infusion
      • 0.1-0.2 units/kg if newly diagnosed

21

DKA Cerebral Edema Dx & Mgmt

  • young, newly diagnosed
  • improving then headache, LOC changes, incontinence
  • prevent by slow correction
  • IV mannitol 1-2 g/kg or hypertonic saline (3%) 5-10 mL/kg over 30 minutes

22

Rhabdomyolysis

  • Dx
    • CK > 5x ULN
      • peaks 24-72 h
      • falls at 39% per day
      • level does not correlate with risk of renal failure
    • myoglobin in urine (but falls 6h after onset of muscle breakdown)
    • check extended lytes, CBC, PTT/INR (for DIC), uric acid, LDH
      • often initial hypocalcemia (later hypercalcemia), hyperphos, hykerK
    • monitored bed
  • Tx
    • NS alternating with D5NS
    • don't use Ringer's
    • no evidence for bicarb or diuretics
    • aim for UO of 2mL/kg/h (200-300 mL/h)
  • Dispo
    • if purely exertional and mild may rehydrate and DC home
    • otherwise admit to monitored bed

23

Adrenal Gland Structure (Read-Through)

  • adrenal cortex
    • cortisol
      • controlled by CRH, ACTH, HPA
        • highest in AM, lowest in evening
    • aldosterone
      • controlled by RAAS & K+ levels
    • sex hormones
  • adrenal medulla
    • adrenaline, noradrenaline, dopamine

24

Symptoms of adrenal insufficiency (cortisol + aldosterone)

  • cortisol: weight loss, lethargy, weakness, decreased LOC, anorexia, NxVx, AP, diarrhea
  • aldosterone: dehydration, syncope, salt craving, orthostatic hypotension 

25

Serum cortisol level to r/o adrenal insufficiency

  • serum cortisol > 18 mcg/dL rules out adrenal insufficiency

26

Addison's Disease

labs

causes

treatment

  • cortisol, aldosterone, sex hormone deficiency
    • ACTH excess --> hyperpigmentation
  • cortisol does not rise with ACTH stimulation test
  • hyponatremia, hyperkalemia
  • autoimmune, sepsis, ketoconazole, TB, infiltrative disorders (ca, sarcoid, etc.), sx, CAH/familial
  • tx lifelong fludrocortisone (Florinef) + glucocorticoid
    • women may need androgens (men make in testes)

27

Secondary Adrenal Insufficiency

labs

causes

treatment

  • cortisol deficiency only 
  • cortisol rises with ACTH stimulation test
  • hyper or hyponatremia, hypokalemia (functioning aldosterone)
  • sudden cessation of chronic steroid use, pituitary apoplexy/tumor/radiation/infiltration/infection
  • tx glucocorticoid only

28

Stress-Dose Steroids

  • 3x daily dose of glucocorticoid dose (give for 24-48 h with f/u to pts with minor illness)
  • mineralocorticoid dose usually stays the same

29

Adrenal Crisis

ssx

tx

  • hypotension refractory to pressors
  • nxvxdx AP
  • tx
    • Hydrocortisone 100 mg IV bolus (has glucocorticoid + mineralocorticoid effects)

30

Pediatric Hypoglycemia

See Evernote "Peds Metabolic Disorders"

31

Inborn Errors of Metabolism

  • nonspecific presentation
  • poor feeding/vx +- acidosis
  • routines, LFT's, ammonia level, VBG, lactate, urine ketones
  • ammonia level
    • normal <65 mm/L
    • can be 2-3x higher in stressed/nonfasting newborns
    • > 200 definitely abnormal
  • Stop feeding
  • Start D5WNS

32

Peds Adrenal Insufficiency

  • 95% is 21-hydroxylase deficiency
  • classic salt-wasting, virilizing
  • all end up in cortisol deficiency but some non salt-wasting
  • classic salt-wasting presents during 2-5th weeks of life in crisis
    • hypo Na+, Hyper K+, metabolic acidosis, virilizing features, skin fold pigmentation
  • NS
  • correct hypoglycemia
  • Hydrocortisone 
    • 25 mg IV neonates
    • 50 mg IV toddlers/school-aged children
    • 100 mg IV adolescents

33

How to treat new Dx Diabetes with Hyperglycemia but no DKA

  • fluids
  • 0.1 u/kg sc Humulin R

34

How to treat hyperglycemia in known DM but no DKA

  • 10% total daily insulin dose as Humulin R
  • 5-10% Q4-6h until illness resolves/ketonuria resolves if T2DM with intercurrent illness but no DKA

35

Management of Hyperthyroidism (non-storm)

  • metoprolol 25 mg PO BID
  • med clinic

36

Target rate of glucose drop in DKA

2-5 mmol/L/h