Endocrine emergencies

Question 1

Addisonian crisis is..

Answer 1

Acute insuffieciency of adrenal glands

Very low cortisol levels

Question 2

Addisonian crisis can be caused by..

Answer 2

Acute exacerbation of addison’s/hypopituitarism (sepsis, surgery, not taking meds)
Adrenal haemmorhage (birth trauma, Waterhouse Friedrichsen)
Steroid withdrawal
Surgical adrenalectomy
Sheehan’s syndrome

Question 3

Addisonian crisis presentation

Answer 3

NandV, abdo pain, weight loss, fatigue

Shock
Hyponatraemia
Hyperkalaemia
Hypoglycaemia

Question 4

Addisonian crisis management

Answer 4

Hydrocortisone IM/IV
Saline (with dextrose if hypoglycaemic)
ABX if septic

Monitor electrolyte imbalance (hyperkalaemia)

no fludrocortisone needed (hydrocortisone exerts mineralocortioid action)

Question 5

What are the precipitating factors in DKA

Answer 5

Infection (increases insulin requirement)
Missed insulin dose
Undiagnosed/newly diagnosed T1D
Acute illness - MI, stroke, pancreatitis, surgical stress

Question 6

DKA pathphysiology

Answer 6

Hyperglycaemic state

Lack of insulin -> glucose cannot enter cells -> low IC glucose levels -> body tries to produce glucose via gluconeogenesis, glycogenosysis, lipolysis -> high level of ketone bodies -> metabolic acidosis

Question 7

DKA presentation

Answer 7

Polyuria, polydipsia, dehydration (due to hyperglycaemia)
N&V
Abdo pain
Kussmaul respiration (deep hyperventilation)
Acetone breath (pear drops)

Question 8

DKA diagnosis

Answer 8

Glucose >11mmol
pH <7.3
Bicarbonate <15
Ketones >3 mmol or ++ on urine dipstick

Question 9

DKA management

Answer 9

Saline (fluid replacement)
Insulin and then IV dextrose when glucose <15mmol (to avoid hypo)
Potassium (to correct hypokalaemia)

Monitor blood glucose, fluid balance, serum bicarb, ketones and UandEs regularly

Question 10

What can cause a thyroid storm?

Answer 10

Thyroid or non-thyroidal surgery
trauma
infection
acute iodine load e.g. CT contrast media

Question 11

Thyroid storm features

Answer 11

fever > 38.5ºC
tachycardia
confusion and agitation
nausea and vomiting
hypertension
heart failure
abnormal liver function test - jaundice may be seen

Question 12

Thyroid storm treatment

Answer 12

symptomatic treatment e.g. paracetamol
treatment of underlying precipitating event
beta-blockers: typically IV propranolol
anti-thyroid drugs: e.g. methimazole or propylthiouracil (thionamides)
Lugol’s iodine
dexamethasone - e.g. 4mg IV qds - blocks the conversion of T4 to T3