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RCSI EMERGENCIES COPY > ENDOCRINE > Flashcards

ENDOCRINE Flashcards

1
Q

addison crises

A

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

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2
Q

addison crises RF predisposing

A 
existing adrenal disease (primary adrenal disease , adrenalitis) 
female 
long term steroid 
infiltration (TB, sarcoid, mets) 
Heparin and Warfarin 
Coeliac (11X increase)
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3
Q

addison crises RF precipitates

A 
Abrupt withdrawal of exogenous steroids
Pituitary infarct
Surgical cure of Cushing’s syndrome
Concomitant infection/illness
Adrenal haemorrhage
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4
Q

signs addison crises

A 
Volume depletion/Shock
Hypotension
Particularly postural
Coma
Febrile/fever
Hyper-pigmentation
If long standing adrenal insufficiency
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5
Q

symptoms of addison crises

A 
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)
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6
Q

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

A 
Hyponatraemia
Hyperkalaemia
Elevated Urea: (volume depletion secondary to Urinary Na loss)
Hypercalcaemia
hypoglucose 
NOT: HYPOvelemia
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7
Q

ACTH levels in addison crises

A

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

Secondly cause - decrease ACTH

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8
Q

why fluid do u give in addison crises

A
  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
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9
Q

ACUTE treatment for addison crises

A
  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
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10
Q

LONG TERM treatment addison crises

A 
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

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11
Q

Sick day rule for steroids addison crises

A

Double dose of steroid for sick days

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12
Q

DKA definition

A

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

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13
Q

RF for DKA

A

Predisposing

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

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

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14
Q

signs DKA

A 
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
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15
Q

symptoms

SKA

A 
Glycosuria
Polyuria
Polydipsia
Weight loss
Lethargy
Nausea 
Vomiting (secondary gastroparesis)
Abdominal Pain:
Muscle cramps
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16
Q

osmolarity in DKA

A

Hyperosmolality/hyperglycaemia/acidosis

with increase anion gap

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17
Q

ecg in DKA

A

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

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18
Q

gnereal DKA treatment

A

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

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19
Q

Potassium monitoring & replacement

A

<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

20
Q

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

A

DECREASE

21
Q

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

A
  • patient must have free ketones for 24 hours, eating and drinking before you switch
22
Q

Complications of DKA

A
  1. cerebral edema and osmotic demyelination (if Na is correct too fast)
  2. aspiration pneumonitis
  3. sepsis
  4. ACS
23
Q

treatment of cerebral edema and osmotic demyelination complication in DKA

A

Mannitol and may need IV dexamethasone

24
Q

HHS definition

A

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

25
Q

RISK HHS

A

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
26
Q

osmolarity in HHS

A

osmolarity > 320 mosmol

27
Q

ph in hHS

A

non acidic therefore NORMAL

28
Q

ABGs in DKA

A

low Ph
high bicarb
incase pCO2

29
Q

Treatment HHS

A

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

30
Q

aim to lower glucose when treating HHS

A

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

31
Q

when do you add glucose to fluid when correcting HHS

A

add glucose to fluid when the blood glucose DROPS to 14

32
Q

when do you adjust insulin requirements when treating HHS

A

When reaches 13.9 to 16.7 mmol/L

IV insulin can be tapered and SC insulin started.

33
Q

HHS target blood glucose

A

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

34
Q

potassium replacement in HHS

A

<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

35
Q

complications of HHS

A

Seizures, cerebral oedema and central pontine myelinolysis

DVT, MI, stroke

36
Q

myxoedema coma

A

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

37
Q

ABG myxoedema coma

A

Resp failure

38
Q

myxoedema coma treatment

A

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

39
Q

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.

A

Temperature of 35.4 degrees centigrade

40
Q

definition for endocrine thyrotoxic storm

A 
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
41
Q

RF for thyroidtoxic storm precipitating

A 
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
42
Q

thyroid toxic storm organ involvement

A 
Multi-system decompensation:
Cardiac failure
Respiratory distress
Congestive hepatomegaly
Dehydration
Pre-renal failure
43
Q

what do you see on FBC with thyroidtoxic storm

A

normacystic anemia
mild neutropenia
leucocytosis
thrombocytopenia

44
Q

treatment of thyroidtoxic storm

A

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

45
Q

resistant treatment of thyroidtoxic storm

A
  1. plasmapheresis
  2. peritoneal dialysis
  3. cholestyramine
46
Q

what makes thyroidtoxic storm worse

A

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

RCSI EMERGENCIES COPY (5 decks)

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