Endocrine Emergencies

Question 1

Diabetic Ketoacidosis

Answer 1

1. ABCDE & evaluate for ITU
2. cannulate 2 large bore
3. A/VBG: pH, bicarb, U&E, ketones, glucose
4. INSULIN
   50 Units actrapid in 50ml 0.9% saline. Keep going until ketones <0.3 and bicarb >7.3
5. Repeat VBGs at 1hr 2hrs then 2hrly

Systemic support:
Urinary catheter if low urine output
NG tube if vomiting

Homeostasis
K+ replacement when falls below 5.5
10% Glucose once falls below 14.

Question 2

Hypoglyceamic coma

Answer 2

1. ABCDE: manage airway if GCS <8
2. GLUCOSE
   200-300mL of 10% Dextrose
3. GLUCAGON 1mg / prolonged dextrose infusion
4. Encourage Oral intake once alert

Question 3

Hyperglyceamic HyperOsmolar Non-Ketotic Coma

HONK

Answer 3

1. ABCDE: manage airway
2. Rehydrate slowly, 0.9% Saline IVI/48hrs
3. LMWH
4. Monitor urine output
5. Assess K+ status once urine produced- replace
6. Keep glyceamic control 10-15 for 24 hrs
7. If rehydration ineffective, introduce insulin infusion very slowly.

Question 4

DM Lactic Acidosis

Answer 4

Serious complication rarely found in metformin users/ septic diabetics
1. IDENTIFY
Lactate >5mmol/L
2. GET HELP
need senior & specialist input
3. STOP METFORMIN & AGGRESSIVELY MANAGE SEPSIS

Question 5

Myxoedema- Coma (peri-arrest hypothyroid state)

Answer 5

1. ABCDE
2. Move to HDU / ITU when available
3. High flow O2 +/- ventilation
4. Bloods: TFT, U&E, FBC, cortisol, BM, ABG
5. Correct hypoglyceamia
6. Give T3 10micrograms/12hr IVI
7. Hydrocortisone 100mg/ 8hrs IVI
8. Active warming
9. Slow rehydration and observe fluid levels
10. After 3 days improvment move to Levythyroxine

Question 6

Thyrotoxic storm (hyperthyroid crisis)

Answer 6

1. FLUID BALANCE 
 IV access. Fluids, Catheter, NG
2. BLOODS
TFT, cultures
3. SEDATE 
50mg IM Chlorpromazine
4. BETA-BLOCK
Propanalol 40mg/8hrs
OR in asthma/ poor CO use short acting ESMOLOL
OR if BBcontraindicated use DILTIAZEM
5. DIGOXIN if futher slowing needed
6. ANTITHYROID DRUGS
carbimazole 20mg/6hrs
Lugols solution (aqueous iodine) after 4hrs for 7 days
7. STEROIDS
block peripheral T4-T3 conversion Hydrocortisone 100mg/6h IVI 
OR Dexamethasone 4mg / 8hrs oral
8. COOLING
9. IF NO IMPROVMENT_= THYROIDECTOMY 
10. 10/7 regime
-after 5 reduce carbimazole
-after 10 stop propanalol and iodine

Question 7

Addisonion Crisis

Answer 7

1. HYDROCORTISONE 100mg IV stat
2. IV Fluid Bolus, support BP
3. BLOODS
   Cortisol, ATCH, U&Es review and treat results
4. BM- give IVI dextrose
5. Calcium Gluconate for hyperkalaemia
6. Antibiotics for precipitating infection
7. maintain hydrocortisone, 100mg / 8hrs for 72 hours then change to oral steroids

Question 8

Hypopituitary Coma

Answer 8

1. HYDROCORTISONE 100mg/ 6hrs IVI
2. Bloods: TFT, Cortisol, ATCH, Glucose
3. Liothyronine slow IV or oral once steroids established
4. Treat cause- usually transphenoidal surgery

Question 9

Phaeochromocytoma Hypertensive Crisis

Answer 9

ITU: SENIOR HELP. ABCDE

Treatment is based around alpha and beta blockade.

1. Alpha Blockers 2mg Phentolamine IV
2. Repeat until Normotensive
3. Switch to long acting Alph-blocker PHENOXYBENZAMINE
4. Add in B-BLocker
5. Control BP for 4-6 weeks then surgical intervention