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Endocrine Emergencies Flashcards

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1
Q

Pathophysiology of DKA

A 
Body's response to cellular starvation
Relative insulin deficiency
Counterregulatory excess (glucagon)
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2
Q

Why does one become acidotic in DKA?

A

Relative insulin deficiency
Cellular starvation
Lipolysis with subsequent fatty acid transport to hepatocytes
Formation of ketoacids
Ketonuria
Anion gap metabolic acidosis with capensatory tachypnea
Vomiting

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3
Q

Why does one become dehydrated in DKA?

A

Relative insulin deficiency
Hyperglycemia increases osmotic load and leads to glycosuria
Water drawn out of cells via oncotic pressure
Impaired consciousness
Shock

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4
Q

Presentation of DKA

A

Hyperglycemia
Acidosis from ketoacids
Volume loss

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5
Q

Presentation of Hyperglycemia

A

Polydipsia

Polyuria

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6
Q

Presentation of Acidosis from Ketoacids

A

Tachypnea

Fruity odor of breath

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7
Q

Signs of Dehydration

A

Dry membranes
Poor skin turgor
Delayed capillary refill
Mental confusion

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8
Q

Management of DKA

A 
Aggressive fluid therapy (NS)
Place monitor
2 large bore IVs
Bedside glucose, urine dipstick, EKG
CBC, CMP, phosphate, and magnesium
ABGs
Blood cultures/other labs as indicated
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9
Q

Fundamentals of Treatment of DKA

A

Volume repletion
Reversal of metabolic consequences of insulin insufficiency
Correction of electrolyte and acid-base imbalances
Treatment of precipitating cause
Avoid complications

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10
Q

Why does fluid administration help with a decrease in blood glucose and ketone concentration?

A

Increases GFR

Allows for glucose and ketones to be excreted

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11
Q

Insulin Therapy in DKA

A

0.1 units/kg/hr after fluid bolus
Use infusion pump for less complications, flexibility in adjusting dose
AVOID IM and subQ doses

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12
Q

What is the most life-threatening electrolyte derangement during treatment of DKA?

A

Hypokalemia

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13
Q

Goals of Potassium Therapy in DKA

A

Maintain normal extracellular K during acute phase

Replace intracellular K over several days

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14
Q

Hypokalemia in DKA due to Therapy

A

Cardiac arrhythmias
Respiratory paralysis
Paralytic ileus
Rhabdomyolysis

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15
Q

Complications of DKA

A 
Hypoglycemia
Cerebral edema
Hypokalemia
Hypophosphatemia
Adult respiratory distress syndrome
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16
Q

Reasons for DKA in NOT a New Onset Diabetic

A

Compliance issues
Discontinuation of insulin
Insults to the body such as infection, MI, PE

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17
Q

What condition occurs in patients with poorly controlled or undiagnosed type II DM?

A

Hyperosmolar hyperglycemic state

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18
Q

Define Hyperosmolar Hyperglycemic State

A 
Serum glucose: 600+ mg/dL
Plasma osmolality: 315+ mOsm/kg
Bicarbonate: 15+
Arterial pH: 7.3+
Serum ketones negative
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19
Q

Shared Symptoms of DKA and Hyperosmolar Hyperglycemic State

A 
Hyperglycemia
Hyperosmolality
Severe volume depletion
Electrolyte imbalances
Acidosis??
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20
Q

Mortality Rates in DKA and Hyperosmolar Hyperglycemic State

A

DKA: 5%
HHS: 15-30%

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21
Q

Risk Factors of Hyperosmolar Hyperglycemic State

A

Inability to access water

Non-ambulatory patients

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22
Q

Presentation of Hyperosmolar Hyperglycemic State

A 
Elderly
Abnormalities in vitals or mental status
Precipitated by acute illness
\+/- baseline cognitive impairment
Weakness
Anorexia
Fatigue
Cough
Dyspnea
Abdominal pain
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23
Q

Treatment of Hyperosmolar Hyperglycemic State

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A 
Volume repletion
Correction of electrolyte abnormalities
Treat precipitating cause
Correction of hyperglycemia
Judicious management of concurrent illness
24
Q

Neurogenic (Increased ANS Activity) Hypoglycemia Signs and Symptoms

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A 
Sweating
Pallor
Tachycardia
Palpitations
Tremor/shaking
Nervousness/anxiety
Tingling, paresthesias
25
Neuroglycopenic (Lack of Sugar to Brain) Hypoglycemia Signs and Symptoms
``` Headache Drowsiness Lightheadedness or syncope Mental dullness or confusion Amnesia Seizure Coma ```
26
At what glucose level do neurogenic symptoms appear?
Approximately less than 54 mg/dL
27
At what glucose level do neuroglycopenic symptoms appear?
Approximately less than 47 mg/dL
28
Define Hypoglycemia Unawareness
Development of low serum sugar values without physiologic ability to react
29
Patients at Greatest Risk for Hypoglycemia Unawareness
Extremes of age Co-morbidities Medications
30
Outpatient Recommendations for Treatment of Hypoglycemia
15-20 g of glucose Retest glucose in 15 minutes Prescribed glucagon Alter insulin or dosage adjustment of oral medication
31
ED Management of Hypoglycemia
``` 1 g/kg body weight dextrose Retest glucose q30 for 2 hours Oral replacement (300g) Glucagon 1 mg IM/IV Octreotide ```
32
Other Considerations for Hypoglycemia in Non-Diabetic Patients
ETOH | SEpsis
33
What does the adrenal medulla secrete?
Epinephrine | Norepinephrine
34
What does the adrenal cortex secrete?
Mineralocorticoids (aldosterone) Glucocorticoids (cortisol) Sex hormones
35
Function of Adrenocorticotropic Hormone (ACTH)
Stimulate synthesis and secretion of adrenocortical hormones
36
Define Adrenal Insufficiency
Failure of adrenal glands to produce essential BASAL secretion of steroids
37
Symptoms of Insidious Wasting Disease in Adrenal Insufficiency
``` Weight loss Fatigue Lack of ambition Hypotension Hyper-melanoma ```
38
Define Adrenal Crisis
Failure to RESPOND to the increased demands caused by stress or SUDDEN INABILITY to secrete essential steroids
39
Define Primary Adrenal Insufficiency
Results from destruction or dysfunction of the adrenal cortex
40
Define Secondary Adrenal Insufficiency
Results from inadequate stimulation of adrenal cortex by ACTH
41
Where is adrenal crisis seen?
Undiagnosed primary adrenal insufficiency subjected to major stress Known adrenal insufficiency who doesn't take extra steroids during major stress After bilateral adrenal infarction or hemorrhage
42
Presentation of Adrenal Crisis
Marked hypotension | Abdominal and flank pain
43
Treatment of Adrenal Crisis
IV glucocorticoids | D5NS: correct hypovolemia and hypoglycemia
44
Signs and Symptoms of a Pheochromocytoma
``` Episodic or sustained Palpitations Sweating Headaches Fainting spells HTN emergencies ```
45
Key History of Pheochromocytoma
Episodes of HTN, headache, palpitation, and sweating
46
Diagnosing a Pheochromocytoma
Demonstrating elevated urinary excretion of catecholamines or metabolites DURING a hypertension period
47
Lab Levels in Hypothyroidism
TSH: high | T4, T3: low
48
When does myxedema occur?
In individuals with long-standing preexisting hypothyroidism presents with life-threatening decompensation
49
Most Common Patient Population
Geriatric patients
50
Presentation of Myxedema
``` Alteration in mental status Hypothermia Bradycardia Hypotension Hypoventilation Cardiovascular collapse Decreased drug clearance History of primary hypothyroidism, previous thyroid surgery, or hypercholesterolemia ```
51
What is myxedema coma generally preceded by?
Medication non-compliance Cold exposure Severe infection Addition of new medications
52
Laboratory Findings in Myxedema Coma
``` Anemia Hyponatremia Hypoglycemia Elevated transaminases Elevated CPK Elevated lactate dehydrogenase Hypercholesterolemia Decreased PO2 Increased PCO2 ```
53
Treatment of Myxedema Coma
``` Stabilization Correction of hypothermia (passive external rewarming) IV levothyroxine Routine administration of glucocorticoid Gentle fluid restriction ```
54
Hyperthyroidism Symptoms
``` Heat intolerance Palpitations Weight loss Sweating Tremor Nervousness Weakness Fatigue ```
55
What is a thyroid storm potentially preceded by?
``` Infection Trauma DKA MI CVA Thromboembolic disease Surgery Withdrawal of thyroid medications Iodine administration ```
56
Symptoms Seen in Thyroid Storm but not Hyperthyroidism
Fever Arrhythmias CHF CNS dysfunction: agitation, confusion, delirium, stupor, coma, seizure
57
Treatment of Thyroid Storm
Stabilization Beta-blockers: severe adrenergic symptoms Antithyroid agents Iodine: decrease preformed thyroid hormone

Emergency Medicine (17 decks)

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