ENDOCRINE

Question 1

addison crises

Answer 1

life threatening emergency due to acute adrenal insufficiency (decrease in MC - aldosterone and GC -corticosteroids

Question 2

addison crises RF predisposing

Answer 2

existing adrenal disease (primary adrenal disease , adrenalitis) 
female 
long term steroid 
infiltration (TB, sarcoid, mets) 
Heparin and Warfarin 
Coeliac (11X increase)

Question 3

addison crises RF precipitates

Answer 3

Abrupt withdrawal of exogenous steroids
Pituitary infarct
Surgical cure of Cushing’s syndrome
Concomitant infection/illness
Adrenal haemorrhage

Question 4

signs addison crises

Answer 4

Volume depletion/Shock
Hypotension
Particularly postural
Coma
Febrile/fever
Hyper-pigmentation
If long standing adrenal insufficiency

Question 5

symptoms of addison crises

Answer 5

Confusion
Collapse/Faints
Particularly when stand up
Acute abdomen
Anorexia, nausea, vomiting, diarrhoea, weight loss & pain
Anorexia
Fatigue
Psychiatric features
Myalgia, arthralgia, muscle cramps (high K)

Question 6

NA, K , urea, Calcium , glucose, volume findings of addison crises

Answer 6

Hyponatraemia
Hyperkalaemia
Elevated Urea: (volume depletion secondary to Urinary Na loss)
Hypercalcaemia
hypoglucose 
NOT: HYPOvelemia

Question 7

ACTH levels in addison crises

Answer 7

if primary (Autoimmune, TB , nets or Waterhourse friderichsen syndrome) - HIGH

Secondly cause - decrease ACTH

Question 8

why fluid do u give in addison crises

Answer 8

1. CALL for help
2. IV fluids - crystalloid - NaCl 0.9%
   Avoid hypotonic saline… worsens hyponatraemia
   Can substituted Dextrose 5% if hypoglycaemic, but beware inducing seizures secondary to worsening hyponatraemia

Question 9

ACUTE treatment for addison crises

Answer 9

1. Call for help
2. IV fluids - NaCl 0.9%
3. Urinary Cauterization
4. IV hydrocortisone - 100mg-200mg stat (Every 4-6 hour)
   alternating with Dexamethasone 4mg, IV OD x 3/7

Question 10

LONG TERM treatment addison crises

Answer 10

Oral dosing, two drugs usually
Glucocorticoid: 
e.g. Hydrocortisone
Often morning (+/- lunchtime, evening)
e.g. hydrocortisone PO 15mg mane, 5mg at lunch, 5mg tarde

Mineralocorticoid:
e.g. fludrocortisone Acetate 0.1mg OD

Wear a bracelet/alert
Don’t forget bone protection, prophylaxis against gastritis
Yearly HBA1c, U&E, lipid profile, BP checks

Question 11

Sick day rule for steroids addison crises

Answer 11

Double dose of steroid for sick days

Question 12

DKA definition

Answer 12

A hyperglycaemic crisis, with…Dehydration AND ketones

A life threatening complication

Hyperglycaemic state (not as high as HHS, i.e. > 11.1mmol/L)

significant fluid deficit: (often 5-8L) (less than HHS)

Importantly: positive ketones in urine or serum

Acidotic: pH < 7.3, Bicarbonate < 18mmol/L

Question 13

RF for DKA

Answer 13

Predisposing

• T1DM
• YOUNG
• OFTEN - never dx, female (skipping meals) , poor nutrition

Precipitating
- sepsis
inadequate insulina ttreatment
iatrogenic drug ( steroids, cociane )

Question 14

signs DKA

Answer 14

Tachypnoea:
Ketotic breath
Kussmauls breathing 
Neurological signs:
Reduced GCS
Confusion... Coma
Seizures
Volume depletion:
Decreased skin turgor
Dry mucous membranes
Tachycardia
Low JVP
Hypotension/particularly postural
Oliguria
Succussion splash, absent bowel sounds

Question 15

symptoms

SKA

Answer 15

Glycosuria
Polyuria
Polydipsia
Weight loss
Lethargy
Nausea 
Vomiting (secondary gastroparesis)
Abdominal Pain:
Muscle cramps

Question 16

osmolarity in DKA

Answer 16

Hyperosmolality/hyperglycaemia/acidosis

with increase anion gap

Question 17

ecg in DKA

Answer 17

Rate… How tachycardic
Rhythm… Any arrhythmia present
Strain or ischaemia… Any TWI, ST changes
Any evidence of MI as trigger for DKA or complication from AKI or electrolyte imbalance

Question 18

gnereal DKA treatment

Answer 18

Fluid replacement
- 0.9% saline per kg in 12-20ml.kg/h OR 1L state , 1L over 2 hours, 1L over 2-4 hours 1L 2-6h, 1L over 8h

Insulin
Act rapid - 5-10U (saintaince 50U diffused into 50mls of 0.9% saline
Aim to decrease glucose by 5mmol/h

Potassium monitoring & replacement (In that order!!) - at least 50mls/h

Prophylactic SC heparin or LMWH

IV antibiotics if warranted

Acidosis correction

Question 19

Potassium monitoring & replacement

Answer 19

<3.3mmol/L - add 40 mEqKCL to 1 L of infusing IV

3.3-5.3 - add 20meQ to iL of infusing IV fluid

> 5.3 - stable - observe and respect K levels in 2 hours , stop any K infusions

Unstable : - cardioprotect for hyperkalemia and then consider dialysis

Question 20

what happens to Na , K , phosphate ,mg and ca in DKA

Answer 20

DECREASE

Question 21

when do you switch a DKA patient from IV to subcutaneous insulin

Answer 21

• patient must have free ketones for 24 hours, eating and drinking before you switch

Question 22

Complications of DKA

Answer 22

1. cerebral edema and osmotic demyelination (if Na is correct too fast)
2. aspiration pneumonitis
3. sepsis
4. ACS

Question 23

treatment of cerebral edema and osmotic demyelination complication in DKA

Answer 23

Mannitol and may need IV dexamethasone

Question 24

HHS definition

Answer 24

hyperglycaemic > 30 mmol/l
- fluid losses: 100 -220 ml/kg
- no ketones
(in many ways more sinister as patient is often older with more co-morbidities and onset is insidious)

osmolarity > 320 mosmol

Question 25

RISK HHS

Answer 25

Predisposing Type 2 diabetes (some residual insulin secretion is usually present: thus reducing the risk of DKA) > 65 years of age Often: patient never previously diagnosed with diabetes ``` Precipitant Sepsis MI/stroke Elevated stress hormones (cortisol/glucagon) Inadequate insulin therapy Decreased water intake Iatrogenic: Steroids, thiazide diuretics ```

Question 26

osmolarity in HHS

Answer 26

osmolarity > 320 mosmol

Question 27

ph in hHS

Answer 27

non acidic therefore NORMAL

Question 28

ABGs in DKA

Answer 28

low Ph high bicarb incase pCO2

Question 29

Treatment HHS

Answer 29

Fluid replacement 0.9% Nacl (15-20ml stat) or IL over... etc Insulin Act rapid 0.1u/kg as boules (if K > 3.5) Potassium monitoring & replacement (In that order!!) Early senior/specialist review. Prophylactic LMWH IV antibiotics if warranted

Question 30

aim to lower glucose when treating HHS

Answer 30

decrease glucose at a rate of ~3 mmols/hour Double dose of IV insulin infusion if not reaching target. (IV dose 0.1u/kg)

Question 31

when do you add glucose to fluid when correcting HHS

Answer 31

add glucose to fluid when the blood glucose DROPS to 14

Question 32

when do you adjust insulin requirements when treating HHS

Answer 32

When reaches 13.9 to 16.7 mmol/L | IV insulin can be tapered and SC insulin started.

Question 33

HHS target blood glucose

Answer 33

Target blood glucose (JBDS): 10-15 mmol/L in the first 24 hours.

Question 34

potassium replacement in HHS

Answer 34

<3.3mmol/L - add 20- 40 mmil KCl o 1 L of infusing IV 3.3-5.3 - add 20 -30 mmol to iL of infusing IV fluid > 5.3 - stable - observe and respect K levels in 2 hours , stop any K infusions Unstable : - cardioprotect for hyperkalemia and then consider dialysis

Question 35

complications of HHS

Answer 35

Seizures, cerebral oedema and central pontine myelinolysis | DVT, MI, stroke

Question 36

myxoedema coma

Answer 36

life threatening complication of underlying thyroid disease MORTALITY : 30-40% HYPOTHROUDIS STATE + CLINICAL MANIFESTATION * comatose, hypothermic , organ failure

Question 37

ABG myxoedema coma

Answer 37

Resp failure

Question 38

myxoedema coma treatment

Answer 38

IV fluids: Use Saline (0.9% Be cautiou over-load easily (b/c hypotensive) Warming Broad spectrum antibiotics ( if infection suspected) Correct any glucose abnormality: Hypoglycaemia is likely T3 (instead of T4 (initially)) IV i.e. tri-iodothyronine, liothryronine Given Intravenously Dose 5-20mcg... Give slowly! - to prevent arrhythmia IV hydrocortisone E.g. 100mg QID Partially as a “stress dose” Also until coexisting adrenal insufficiency is excluded

Question 39

A 67 year old woman is reviewed in the emergency department with stupor and decreased consciousness. what clinical feature is more suggestive of a diagnosis of Myxoedema Coma rather than Addisonian crisis.

Answer 39

Temperature of 35.4 degrees centigrade

Question 40

definition for endocrine thyrotoxic storm

Answer 40

``` life threatening complication of underlying thyroid disease HYPERTHYROID STATE + clinical manifestation - fever - jaundice - abdo pain - N V D Signs: - febril - confusion - tachycardia w/ arrhythmia Multisystem decompensation ```

Question 41

RF for thyroidtoxic storm precipitating

Answer 41

``` Sepsis Withdrawal of anti-thyroid medication(s) Iatrogenic/OD (eltroxin) Metabolic abnormalities DKA, etc Recent surgery Thyroid Non-thyroid Radio-iodine therapy Iodinated contrast dye ```

Question 42

thyroid toxic storm organ involvement

Answer 42

``` Multi-system decompensation: Cardiac failure Respiratory distress Congestive hepatomegaly Dehydration Pre-renal failure ```

Question 43

what do you see on FBC with thyroidtoxic storm

Answer 43

normacystic anemia mild neutropenia leucocytosis thrombocytopenia

Question 44

treatment of thyroidtoxic storm

Answer 44

IV fluids: Antipyretic Paracetamol AND Chlorpromazine... For hyperpyrexia and agitation Broad spectrum antibiotics: (empiric) - if infection suspected Propanolol - 60-80mg every 4-6 hours (2-5mg/jour IV infusion) Antiarrythmic - DIGOXIN (if in a.fib give anticoagulant first) propthriouracil -200-300QDS Potassium iodide - PO/NG 1-6 hours after propthriouracil 60mg Prednisone PO/ NG OD OR 100mg Hydrocortison

Question 45

resistant treatment of thyroidtoxic storm

Answer 45

1. plasmapheresis 2. peritoneal dialysis 3. cholestyramine

Question 46

what makes thyroidtoxic storm worse

Answer 46

ASA - b/c it displaces T3 and T4 to their protein binding site