HReviewEmergencies

Question 1

DKA

Answer 1

Hyperglycemia, AG with metabolic acidosis and ketonemia

BG 500-800 but much lower in pregnancy and starvation

PH < 7, HCO3< 10 - is sever DKA (severty depends on ph and hco3)

Abd pain

Question 2

DKA DDx

Answer 2

• Alcoholic or starvation ketoacidosis (should nto have hyperglycemia

Non of hte below causes should cauase ketoacidosis

• Lactic acidosis
• ingestion of ASA, Methanol, ethylene glycol
• CKD

Question 3

HHS (hyperosmolar hyperglycemic State)

Dx features

Answer 3

• BG > 600 (often > 1000)
• PH > 7.3
• Bicarb > 20
• Neurologic abnormalities often present
• Mild ketonemia may be present, urine ketones maybe -ve

Question 4

Precipitants of DKA

Answer 4

• Infection
• Complaince
• MI / Stroke / Pancreatitis
• Steroids, 2nd generation antipsychotics
• Cocaine (increases catecholamines)

Question 5

B-hydroxybutyrate

Answer 5

May get false -ve ketone :

Nitroprusside reation only reacts with acetoacetate and acetone not b-hydroxybutyrate (predominant ketone in sever DKA)

May get false +Ve ketones

Sulfhydryl meds like (captopril and penicillamine) react with nitroprusside

Question 6

Managment

Answer 6

1. Address immediately

• ABC / Mental status / Causes (MI / Stroke / Infection)

2. IV isotonic saline due to hyperosmolarity

• replace upt to 10-15 ml / kg lean body weight per hr)

3. K repletion / if k < 5.3 will need 20-30 mEq replacement per hr

• Hold insuline if potassium < 3.5

4. IV insuline

• initial dose 0.14 U/kg/hr (deos not necessitate an IV bolus
• Dose should be doubled if glucose does not fall by 50-70 mg/dL first hr
• will need to hold / delay insulin if K < 3.3 untill replaced

5. Once bg reaches a certain level must starte Dextrose to the IVF

• in DKA BG < 200
• In HHS BG < 300

**6. Barcarbonate may be considered if PH < 7 **

Question 7

DKA resolved when

HHS resolved when

Answer 7

1. AG < 12

KEtoacidosis has resolved

2. BG < 315 and Mental status back to normal

Question 8

Thyroid Storm

Percipitating events:

Answer 8

Percipitating events:

1. Surgery
2. Trauma
3. Infection
4. Acute iodine load
5. Childbirth

Question 9

Assessment of Thyroid storm

Answer 9

TFT’s

Burch Wartofsky criteria but not specific:

• Body temp
• Mental status
• GI/hepatic dysfuction
• tachycardia
• AFib
• Pulmonary Edema

Score > 45 thyroid storm

25-45 - supports dx

< 25 unlikely

Question 10

Tx Thyroid storm

Answer 10

• Thionamides block synthesis of thyroid hormonr
  
  • MMI 20 mg Q4-6 hrs
  • PTU 200 mg Q4H
    
    • PTU also blocks T4-T3 conversion
    • MMI less hepato toxic
• BBLK (make sure no CHF symptoms)
• Iodine - blk release of thyroid hormone (at least 1 hr after MMI)
• Steriod - blockes T4-T3 conversion - also treating the adrenal insufficiency

Question 11

For hyperthyroid fever

Answer 11

Tylenol preferable to ASA

Question 12

Severe Hypothyroidism (myxedema Coma)

Answer 12

• High mortality rate
• can occur Longstanding hypothyroidism / or acute illness (MI, infection, administration of opiates or exposure to cold)
• Any cause of hypothyroidism (lithium or amiodrone)

Question 13

Clinical presenation Severe hypothyroidism

Answer 13

• Decrease Mental status / hypothermia
  
  • could be psychosis
  • Bradycardia / Slow respiratory rate / hypotension / hyponatremia / hypoglycemia / myxedema
  • Myxedema - non pitting edema due to dposits of mucin in skin and other tissues
    
    • puffy appearance of hands and face
    • thickened nose, lips and tongue

Question 14

Tx hypothyroidism (severe)

Answer 14

Admin thyroid hormone: both T4 and T3/ assumption of conversion is impaired.

initial T4 should IV with loading dose of 200-400 mcg followed by weight based 1.6 mcg/kg/day

T3 could also be given at about loading dose of 5-20 mcg with dosing of 2-10 mcg Q8H