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Emergency Med Exam 3 > Endocrine Emergencies > Flashcards

Endocrine Emergencies Flashcards

(53 cards)

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1
Q

Hypoglycemia defined

A

Glucose < 70 mg/dL
Symptomatic hypoglycemia with levels <50

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2
Q

Risk factors for hypoglycemia in type II diabetes

A

Age
PMHx of vascular disease
Renal failure
Decreased food intake
Alcohol use
Drug interactions
Non compliance

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3
Q

Hypoglycemia sympathomimetic symptoms

A

Sweating, tremor, pallor, nausea,
anxiety, palpitations

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4
Q

Hypoglycemia Neuroglycopenia symptoms

A

Dizziness, psychosis, confusion, coma,
agitation, seizures

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5
Q

Hypoglycemia additional causes

A

● Insulinoma- Pancreatic islet cell tumor (90% benign)
● Medications/Drugs/Alcohol
● Extrapancreatic neoplasm
● Hepatic disease(depletion of glycogen stores)
● Deficiency of counterregulatory hormones
● Critically ill, stressed infants, hypothermia
● Dumping syndrome
● Artifactual

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6
Q

Hypoglycemia treatment

A

Standard treatment options
- Oral Glucose
Sugar Water
- D50 (50% dextrose in water) - 50 mL bolus provides 25gm of glucose (500mg/mL)
- D25 (peds)
- D10 (neonates)
- Maintain glucose at > 100 mg/dL
Recheck blood sugar q30 mins
- IV infusion of D10 (10% dextrose in water) or oral to maintain blood sugar
Glucagon 1mg IM/IV
- Stimulates glycogenolysis
- Can raise BS by ↑ 100mg/dL
- Works slower (10-15 minutes)

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7
Q

secondary causes of hypoglycemia if failure to respond to initial therapy

A

Sepsis, toxin, insulinoma, hepatic failure, adrenal insufficiency

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8
Q

Octreotide (Sandostatin)

A
  • Inhibits insulin secretion
  • Helps prevent rebound hypoglycemia in setting of glucose Infusion treatment and persistent symptoms refractory to
    sulfonylurea-induced hypoglycemia (As an antidote)
  • 50-100 mcg SC or IV
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9
Q

Give _____ with glucose in malnourished hypoglycemic patients

A

thiamine

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10
Q

Diagnosis of DM

A
  • Fasting glucose (100-125 mg/dL)
  • Random glucose (>200 mg/dL)
  • 2 hour oral glucose tolerance (>200 mg/dL)
  • HbA1c of >6.5%
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11
Q

Severe Hyperglycemia (>300 mg/dL) treatment

A
  • Fluids IV
  • Insulin -Regular insulin at 0.1- 0.15 units/kg IV or SC (IV better absorption)
    Appropriate to initiate Metformin 500 mg qDay
  • Make sure creatinine is normal
  • If modest elevation, inform patient of concern, F/U PCP
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12
Q

Hypoglycemic medications

A
  • Sulfonylurea agents:
  • (2nd gen) Glipizide, glimepiride, glyburide
  • Stimulate pancreatic insulin secretion
  • Cause profound hypoglycemia in OD
  • Long duration of action
  • Repaglinide (Prandin)
  • Stimulates insulin secretion
  • Can also cause hypoglycemia
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13
Q

Antihyperglycemic Agents (less likely to cause hypoglycemia in overdose)

A

Metformin
- Rarely causes lactic acidosis
Less risk of hypoglycemia
GLP-1 agonist
SGLT2 inhibitors
DPP-4 inhibitors
Thiazolidinediones

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14
Q

Diabetic Ketoacidosis Pathophysiology

A

Defined as cellular starvation due to relative or a
complete lack of insulin:
- Hyperglycemia
- Osmotic diuresis
- Prerenal Azotemia
- Ketone formation
- Wide anion gap metabolic acidosis

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15
Q

Free Fatty acids are converted to Ketones
in the liver → ______

A

Metabolic Acidosis

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16
Q

Hyperglycemia effects on the body

A

Glycosuria
Osmotic diuresis
Decreased GFR
Intracellular dehydration
Impaired consciousness
Shock
(Table on slide 20)

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17
Q

Loss of islet cell function in DKA causes what effects on the body?

A
  • Autoimmune destruction → Type I
  • Leads to inability of cells to use glucose for fuel, despite
    increased levels of intravascular glucose
  • Breaks down protein and adipose stores
  • Increased counterregulatory hormones further leads to
    ketonemia and increased hyperglycemia (Osmotic Diuresis)
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18
Q

Precipitants of DKA

A

Noncompliance with Insulin
Infection
Myocardial Infarction
Pregnancy (IUP)
CVA
Trauma
Hyperthyroidism
Pancreatitis
Any acute stressor

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19
Q

Metabolic acidosis causes compensatory ____

A

hyperventilation
- Kussmaul breathing
- Acetone leads to fruity breath smell

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20
Q

Avenues of volume loss in DKA

A
  • Osmotic Diuresis
  • Vomiting (Acidosis)
  • Loss of potassium
  • Leads to further hyperglycemia
  • Poor absorption of SC Insulin
  • Leads to poor Hemodynamics
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21
Q

Diabetic Ketoacidosis diagnosis

A
  • Glucose >250 mg/dL
  • Anion gap > 10 mEq/L
  • Bicarbonate < 15 mEq/L
  • pH < 7.3
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22
Q

Initial Goals and goal labs in treating DKA

Study These Flashcards
A
  • 1st - Volume replacement
  • 2nd- Potassium Correction
  • 3rd- Insulin Therapy

Goal labs:
- Glucose <200
- Lower Glucose 75 mg/dL/ hr
- >18 mEq/L
- pH >7.3

23
Q

Fluids / Bicarbonate in DKA - treatment

Study These Flashcards
A
  • Initial fluid resuscitation for hypovolemia
  • Replace electrolytes
  • Insulin drip
  • Sodium bicarbonate is rarely indicated
  • As glucose normalizes, start Dextrose
24
Q

What is Pseudohyponatremia

Study These Flashcards
A

Sodium is artifactually decreased 1.6 mEq/L for every
100 mg/dL increase in glucose over 100
- After initial bolus, if eunatremic, then switch to 0.45% saline

25
Complications of DKA Treatment
Hypoglycemia- due to excess insulin Begin giving glucose when glucose = 200-250 Hypokalemia- from insulin, bicarbonate, hydration CSF acidosis- bicarbonate Cerebral edema- Neurologic change
26
How to treat neurologic changes in DKA
50% of fatalities in DKA Possibly over-hydration, hypoxemia, Bicarbonate, rapid osmotic changes Tx- Mannitol, restrict fluid, intubation
27
Alcoholic Ketoacidosis
- Binge drinking with heavy alcohol, - decreased food intake - starvation ketosis - EtOH metabolism inhibits gluconeogenesis - Depletes Glycogen stores - Abdominal pain, nausea, vomiting, dehydration, disorientation
28
Treatment for alcoholic ketoacidosis
- D5 Normal Saline - Thiamine - Electrolyte correction
29
Anion Gap Metabolic Acidosis causes (MUDPILES)
Methanol/ Metformin Uremia Diabetic Ketoacidosis, Alcoholic Ketoacidosis Paraldehyde Iron, Isoniazid, Inhalants Lactic Acidosis Ethylene Glycol (AntiFreeze) Salicylates
30
Hyperosmolar Hyperglycemic Syndrome is similar to DKA except:
- Triggered with concurrent inflammatory condition - Hyperosmolar, No ketoacidosis - Glucose usually higher(>1000)
31
Precipitating factors for HHS
Infection, especially pneumonia Myocardial infarction CVA GI bleed Pyelonephritis Pancreatitis Uremia Subdural hematoma Peripheral vascular occlusion Any stressor
32
Common comorbid conditions with HHS
Renal insufficiency, vascular disease, poor access to water
33
Common associated medications with HHS
Diuretics, B-Blockers, Corticosteroids, Ca++ channel blockers Phenytoin, Cimetidine
34
Physical findings for HHS
- Dehydration, Altered, coma rare Focal neurologic findings
35
Treatment of HHS
Similar balancing act to DKA Normal saline(average fluid deficit 8-12 liters) ½ deficit over first 12 hours, the rest over next 24 hours 1-2 liter bolus clinically indicated Insulin infusion (lower doses than DKA)
36
Hyperthyroidism causes
-Graves’ disease (most common)-an autoimmune disorder thyroid-stimulating immunoglobulins mimic TSH action -Toxic thyroid adenoma, toxic multi-nodular goiter -Thyroiditis -Pituitary adenoma -Drug Induced -Excess iodine in diet
37
Hyperthyroidism S/S
Nervousness, tremor, insomnia Heat intolerance, sweating Weakness, weight loss, hair loss Tachycardia, palpitations Diarrhea Irregular menses Goiter / thyroid bruit Exophthalmos (Graves’ only) Lid lag (lids move slower than eyes) Pretibial Myxedema
38
Thyroid Storm
A life-threatening complication of hyperthyroidism Essentially a severe form of Thyrotoxicosis - Most common cause is Graves Disease
39
Precipitating events for Thyroid storm
Withdrawal of antithyroid meds Administration of IV contrast Thyroid hormone overdose Pneumonia CVA Pulmonary embolism Toxemia of pregnancy Diabetes
40
clinical diagnosis of thyroid storm
Hallmark is CNS dysfunction - Temperature > 38 C - Tachycardia out of proportion to fever - Exaggerated peripheral manifestations of thyrotoxicosis - Including tremor and weakness - GI-Hepatic Dysfunction - Atrial Fibrillation - Congestive Heart Failure
41
T/F No lab tests distinguish thyroid storm from simple hyperthyroidism
T
42
5 step treatment approach to Thyroid storm
1)General supportive care- IV fluids Correct electrolyte imbalance No ASA(displaces thyroid hormone from thyroglobulin) 2) Blockade of thyroid hormone synthesis- - PTU 1000 mg PO (also inhibits peripheral conversion of T4 to T3 3) Blockade of thyroid hormone release Iodine given 1 hour after PTU 4) 𝛃- adrenergic receptor blockade of peripheral thyroid hormone effects- - Propranolol 5) Prevent peripheral conversion of thyroxine to triiodothyronine - Corticosteroids(decrease peripheral conversion T4 to T3)
43
Hypothyroidism causes
- Treatment of Graves’ disease - After ablation - Iodine deficiency in diet - Autoimmune destruction of thyroid gland (e.g. Hashimoto’s) - Lithium therapy for bipolar disorder - Amiodarone - Pituitary and hypothalamic disorders (rare) - External Radiation
44
Hypothyroidism S/S
● Weakness, lethargy ● Cold intolerance ● Hypothermia ● Weight gain ● Constipation ● Dry, thick skin ● Prolonged, heavy periods ● Generalized nonpitting edema ● (myxedema)
45
Myxedema Crisis (severe hypothyroidism) signs
Dermatologic: Coarse, waxy skin, scant pubic hair, Loss of lateral third of eyebrows, puffy face and extremities CNS: Slowed mentation, altered mental status, coma, psychosis(myxedema madness) Cardiac: CHF, bradycardia, hypotension, cardiomegaly, Pericardial effusion, low voltage(ECG)
46
Hypothyroidism - myxedema coma signs
Non-pitting generalized and periorbital edema Altered mental status Hypoxemia Hypothermia Bradycardia Hypotension
47
Myxedema Coma precipitating factors:
Stressors- MI, infections, trauma, cold exposure Drugs metabolized slower, increased effects Non-compliance with thyroid replacement
48
Myxedema Coma treatment
Supportive care: rewarming, fluid support, underlying cause Specific treatment IV thyroxine(T4)- may require large doses IV T3 is not recommended(causes V- tach) Corticosteroids- possible unrecognized adrenal/pituitary Insufficiency Search for underlying cause
49
Adrenal Crisis clinical findings
- Acute stressors with underlying insufficiency - Destruction of hypothalamic-pituitary or adrenal gland - Hypotension refractory to vasopressors - Abdominal pain, nausea, vomiting - Confusion, lethargy - Look for sepsis
50
Adrenal Insufficiency treatment
- D5NS IV - Hydrocortisone - Pressors - Future maintenance for anticipated stressors - Surgery, etc
51
Adrenal insufficiency labs
Chest X-ray Abdominal CT to look at Adrenal glands Brain CT or MRI HIV Screen
52
Acute presentation of adrenal insufficiency
Fever and refractory hypotension
53
Clinical manifestations of adrenal insufficiency
- Cortisol- metabolism of most tissues, glucose regulation - Aldosterone(renal Na+ reabsorption, K+ excretion)

Emergency Med Exam 3 (7 decks)

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