Metabolism & Endocrine Flashcards
This deck covers Chapters 116-120 in Rosens, compromising all of endocrinology, electrolyte disturbances, and acid-base physiology.
What is Conn’s syndrome? Is the K elevated?
Conn’s Syndrome
- Primary hyperaldosteronism
- Hypernatremia
- Hypokalemia
- Hypertension
List 8 causes of hypophosphatemia
- Malnourished
- EtOH abuse
- Hyperventilation
- Sepsis
- NMS
- Insulin
- Diuretics
- Burns
- Hyperparathyroidism
List FOUR tests that can help diagnose adrenal insufficiency
To Diagnose
- AM Cortisol
-
AM ACTH
* Differentiates 1* from 2* (1* = high ACTH) -
ACTH Stimulation Test
* Baseline cortisol
* Give 250mcg of ACTH, measure again at 30/60m
* If cortisol <20, gland doesn’t work (Primary AI)
* Normal patient should double cortisol - 24h Urine for 17-OH Steroids
If in doubt re: diagnosis, give dexamethasone because hydrocortisone has mineralocorticoid activity.
List SIX causes of a high osmolar gap
- EtOH
- Methanol
- Isopropyl Alcohol
- Ethylene Glycol
- DKA
- Mannitol/Sorbitol
- Hyperlipidemia
- CKD
Outline your management of hypercalcemia in the ED
- Fluids, fluids, fluids
- Diuretics are contentious: if you give any, make it Lasix
- Bisphosphonates
- Calcitonin 4 IU/kg
- Hydrocortisone (if granulomatous dz, not cancer)
- Remove offending agent/treat underlying condition
What is the formula for the anion gap? What is the correction for albumin?
Anion Gap
- Na+ - (HCO3- + Cl-)
For every 10 g/L drop in albumin remove 2.5 from expected AG
How would you approach severely symptomatic hyponatremia and how quickly would you correct the serum sodium?
Severe Hyponatremia
- Hypertonic (3%) saline 100ml over 10 mins
- Will inrease Na+ 2-3 mmol/L
- 3% saline = 513mEq/L OR about 0.5 mEq/mL
- Repeat q10min until seizures stop
Sodium Correction
- Target: 120 mEq/L or until not seizing
- Acute: 1 mEq/L/h
- Chronic: 0.5 mEq/L/h, max 12mEq/day
- Administer D5W and DDAVP if corrected too rapidly
How can the measured sodium in patients with hyperglycemia be corrected?
↑ Glucose 10 mmol/L causes ↓ Na+ 3 mmol/L
Differentiate activated hyperthyroidism from unactivated (apathetic) hyperthyroidism
Activated Hyperthyroidism
- 4th decade
- Duration of symptoms: 8 months
- Weight loss: 10 lbs
- Thyroid weight 70 g
- Eye findings: Frequent
- CHF: Common
- Afib: 1/3 of patients
- Depression: Uncommon
Apathetic Hyperthyroidism
- 7th decade (ELDERLY)
- Duration of symptoms: 26 months
- Weight loss: 40 lbs
- Thyroid weight: 45 g
- Eye findings: Rare
- CHF: Common
- AFib: ¾ of patients
- Depression: Common
Differentiate primary and secondary adrenal insufficiency. List FIVE causes of each.
Primary AI = the gland has failed
- Acute
1. Addison’s disease (MCC in the West)
2. TB (MCC worldwide)
3. Waterhouse-Friederich (Neisseria)
4. Trauma
5. Anticoagulation - Chronic
1. Addison’s
2. TB
3. HIV
4. Adrenal mets
5. Adrenalectomy
6. Etomidate
Secondary AI = the pituitary has failed
- Acute
1. Sheehan syndrome
2. Pituitary apoplexy
3. TBI
4. Sepsis - Chronic
1. Pituitary tumor
2. Surgery
3. Steroids
4. Empty Sella
5. Brain rads
List SIX causes of increased ADH
SIADH and Normal
- Increased osmolarity (Na+)
- Decreased BP
- SAH
- Pain
- Medications (SSRI)
- Low pressure, low volume
- Caffeine
The anion gap takes into consideration chloride and bicarb. What are FIVE classic unmeasured anions?
- Albumin
- Lactate
- Ketones
- Sulfate
- Phosphate
- Organic acids
What is the pathophysiology of rhabdomyolysis?
- Depletion of ATP (exercise, drug, trauma) causing…
- ATP-dependent ion channel failure causing…
- Huge increase in intracellular calcium causing…
- Increased muscle contractility
- Protease activity
- Mitochondrial dysfunction causing O2 free radicals
- Apoptosis
List the 6 progressive ECG changes of hyperkalemia
- Peaked T waves
- Loss of P waves
- Widening of QRS
- Sine wave
- Vfib
- Asystole
List 6 causes of hyperkalemia
- Hemolysis
- Renal failure
- Drugs (Spironolactone, ACEi, NSAIDs)
- Tumour lysis syndrome
- Rhabdomyolysis
- Digoxin toxicity
- Amiloride
- Iatrogenic
Give FOUR causes for falsely low anion gap
High levels of unmeasured cations:
- Lithium
- Hypergammaglobulinemia (MM)
- Hypertriglyceridemia
- Bromide toxicity
- Hypoalbuminemia
List SIX triggers for DKA
The 8 “I’s”
- Initial
- Insulin non-compliance
- Infarct (MI/CVA)
- Infection
- Incision (surgery)
- Insemination (pregnancy)
- Intoxication
- Iatrogenic (medication changes)
List SIX symptoms consistent with thyrotoxicosis
List SIX signs consistent with thyrotoxicosis
Symptoms
SOB, exercise intolerance, palpitations, weight loss, appearance change, hair loss, anxiety, temperature intolerance, restless, oligomenorrhea
Signs
Afib, proptosis, tachycardia, CHF, fever, neck swelling, bruit, tremor, hyperreflexia
In regards to the serum glucose, how is diabetes diagnosed?
- Random plasma glucose >11.1 mmol/L
- Fasting plasma glucose >7 mmol/L
List 6 drugs that have been associated with rhabdomyolysis
- Barbiturates
- Benzodiazepines
- Colchicine
- Corticosteroids
- Isoniazid
- Lithium
- MAOIs
- Narcotics
- Neuroleptics
- Phenothiazines
- Salicylates
- Serotonergics
- Statins
- Theophylline
- TCAs
List EIGHT causes of respiratory alkalosis
Central
- Head Injury
- Stroke
- Anxiety
- Pain
- ASA
- Pregnancy
- High-altitude
- Anemia
Pulmonary
- Hypoxia
- PE
- Pneumonia
- Asthma
- Pulmonary edema
- Mechanical ventilation
Explain the phenomenon of paradoxical worsening of ketosis as AKA/DKA is treated.
- AKA/DKA is mostly β-hydroxybutyrate
- As its treated, it is converted to acetoacetate
- Urine dipstick tests acetoacetate, not β-hydroxybutyrate
- Dip looks more positive as treatment starts
List TEN causes of hypercalcemia
Malignancy
- Lung
- Multiple Myeloma
- Bone mets
Endocrine
- Hyperparathyroidism
- Hyperthyroidism
- Vitamin D excess
Granulomatous
- Sarcoidosis
- TB
- Crohn’s
Drugs
- Thiazides
- Iatrogenic calcium
Miscellaneous
- Paget’s
- Dehydration
- Rhabdomyolysis
What is the management of hyponatremia in the asymptomatic or mild-mod symptomatic patient?
Hypovolemic hyponatremia
- NS 0.9% to correct deficit
Euvolemic hyponatremia
- Free-water restriction
Hypervolemic hyponatremia
- Free-water restriction and diuresis +/- dialysis
List SIX causes of metabolic alkalosis
CLEVER PD
- Contraction
- Licorice
- Endocrine (Conn’s, Cushing’s)
- Vomiting
- Excess alkali (Antacids)
- Refeeding/Renal
- Post-hypercapnia
- Diuretics
When would you treat hyponatremia acutely?
Both of:
- Sodium <120 mEq/L
- Altered, focal neuro deficits, or seizing
Treatment
- 3% saline 100 cc IV over 15 minutes (raises Na 2-3 mEq)
List 5 precipitants of myxedema coma
Who is the typical patient that will present with myxedema coma? What will their vitals be like?
Precipitants
- Infection
- Infarction
- Incision (Surgery)
- GI bleed
- Hypoglycemia
- Hypothermia
- Medications
Typical Patients
- Older women
- Thyroidectomy
Vitals
- Hypothermic
- Bradycardic
- Hypotensive
- Altered
What are the ECG changes in hypocalcemia?
- Short PR
- Long QT
- ST depression
- TWI
- U wave
Arrhythmia is uncommon.
Describe the clinical presentation of hypocalcemia
Neuromuscular
- Paresthesias
- Muscle weakness
- Muscle spasm
- Tetany
- Chvostek’s and Trousseau’s signs
- Hyperreflexia
- Seizures
Cardiovascular
- Bradycardia
- Hypotension
- Cardiac arrest
- Digitalis insensitivity
- QT prolongation
Pulmonary
- Bronchospasm
- Laryngospasm
Psychiatric
- Anxiety
- Depression
- Irritability
- Confusion
- Psychosis
- Dementia
How do you calculate how much hypertonic saline to administer to a patient who has severe symptoms but is not actively seizing?
Step 1: Calculate sodium deficit
- NaDeficit = TBW * (NaDesired - NaMeasured)
- Assume TBW = 60% of weight
- Assume NaDesired = 120 mEq/L
Step 2: Calculate volume of 3% saline needed
- 3% saline = 513 mEq/L
- Volume (cc) = (NaDeficit/ 513) * 1000
Step 3: Calculate desired rate of infusion
- Rate = Volume (cc) / [(NaDesired - NaMeasured)*2]
- Assumes max safe rate = 0.5 mEq/hr
Example
A 70kg man presents twitching with a sodium of 112. Assuming this is chronic, how much and how fast will you correct him?
Step 1:
- NaDeficit = TBW * (NaDesired - NaMeasured)
- NaDeficit = (0.6*70) * (120 - 112)
- NaDeficit = 42 * 8
- NaDeficit = 336 mEq
Step 2:
- Volume (cc) = (NaDeficit/ 513) * 1000
- Volume (cc) = (336/ 513) * 1000
- Volume (cc) = 655 cc
Step 3:
- Rate = Volume (cc) / [(NaDesired - NaMeasured)*2]
- Rate = 655 / [(120 - 112)*2]
- Rate = 655 / 16
- Rate = 41 cc/hr for 16 hours
List EIGHT causes of high anion gap metabolic acidosis
MUDPILES CAT
- Methanol/Metformin
- Uremia
- DKA
- Propylene glycol/Paraldehyde
- Iron, INH
- Lactate
- Ethylene Glycol
- Salicylates
- CO, Cyanide
- Alcoholic Ketoacidosis
- Toluene
How is acid sensed in the body? How is H+ maintained?
pH Sensing
- Central = Medulla
- Peripheral = Carotid body
H+ Homeostasis
- H/K+ renal antiporter
- Carbonic anhydrase
- Buffering capacity
What is a delta gap? How do you calculate it?
Used to assess if more than just HAGMA
- Delta Gap: Change in AG / Change in Bicarb
- Remember alphabetical A(G) before B(icarb)
The ratio gives one of four results:
- <0.4 due to a pure NAGMA
- 0.4 – 0.8 due to a mixed NAGMA + HAGMA
- 0.8 – 2.0 due to a pure HAGMA
- >2.0 due to a mixed HAGMA + metabolic alkalosis
Here’s a worked example:
- Hgb 142 WBC 17 Plt 355
- Na 136 K 5.3 Cl 115 HCO3 7 Urea 28.6 Cr 522 Glc 5.5
- Ca 2.49 PO4 1.52 Mg 1.02 Albumin 36
- EtOH < 1 Acetaminophen < 13 Salicylates < 0.1
- VBG: pH 6.94 pCO2 30 HCO3 6 BE -26
- Lactate 2.4
- B-hydroxybutyrate 1.55
Calculate the delta ratio
- Delta ratio = [AG-12] / [24-HCO3]
- Delta Ratio = (14-12) / (24-7)
- Delta Ratio = 0.117
Define the following:
- Wolff-Chaikoff Effect
- Jod-Basedow Effect
Wolff-Chaik_OFF_ Effect
- Excess iodide inhibits trapping + thyroglobulin iodination
- Excess iodide blocks thyroid hormone release
Jod-Basedow Effect
- Excess iodide induces more thyroid hormone creation
- Can cause hyperthyroidism in patients with multinodular goiter and Graves’ disease
List 5 glucoregulatory hormones and describe their mechanism of action
-
Insulin (ANABOLIC)
* Augments hepatic glucose uptake and storage
* Inhibits gluconeogenesis and glycogenolysis -
Glucagon (CATABOLIC)
* Released by α-cells of pancreatic islets
* Triggers for release: hypoglycemia; stress, trauma, infection, starvation, exercise
* Increases hepatic adenyl cyclase activity = increased gluconeogenesis and glycogenolysis -
Epinephrine (CATABOLIC)
* Increase hepatic glycogenolysis + gluconeogenesis - Cortisol (CATABOLIC)
- GH (CATABOLIC)
* Neither cortisol nor GH are rapid glucose changers
How do you treat suspected adrenal crisis?
For Patient with KNOWN AI:
- Hydrocortisone is preferred because it has intrinsic mineralocorticoid activity
For Patient with UNCONFIRMED AI:
- Dexamethasone is preferred because it does not have mineralocorticoid activity and does not interfere with the ACTH stimulation test
List EIGHT triggers of thyroid storm
- Infection
- Brain bleeds
- Head injury
- Iatrogenic (over-medicated)
- Amiodarone
- Burns
- Thyroid surgery
- Pregnancy
- CHF
- PE
- Hyperemesis
How would you treat hypocalcemia in the ED?
If peripheral IV:
- 2 amps Calcium gluconate
- 1 amp CaGluconate = 93 mg Ca
If central IV/Arrest:
- 1 amp Calcium chloride
- 1 amp CaCl = 272 mg Ca
Note:
- Replace magnesium if refractory
- Stop if bradycardic/AVB
- Effects last 2 hours (think hyperK)
How do you manage thyroid storm?
PCP’s
- Propranolol (60 mg PO)
- Blocks conversion/symptoms
- Corticosteroids (Hydrocortisone 200 mg IV)
- Blocks conversion/autoimmune
- PTU (1000 mg PO)
- Blocks synthesis
- SSKI (5 drops, 1 hour after PTU)
- Blocks release
List the 5 most common causes of hypokalemia
Renal losses
- Diuretics
Non-renal losses
- Vomiting
- Diarrhea
Decreased intake
- Malnourished
- Alcoholism
Intracellular shift
- Hyperventilation
- Insulin
- Sympathomimetics
Endocrine
- Conn’s
- Cushing
- Bartter’s syndrome
Provide FIVE causes of a “double gap” (Anion + Osmolar)
- Methanol
- Ethylene glycol
- DKA
- AKA
- Sepsis
- Chronic Renal failure
How does amiodarone cause thyroid issues?
- Has iodine in it
- Structurally similar to T4
- Can cause thyrotoxicosis
- Directly toxic to the gland
List EIGHT causes of rhabdomyolysis
- Prolonged immobilization
- Excessive exercise
- Muscle ischemia
- Temperature extremes
* Heatstroke, NMS, MH
* Hypothermia - Electrical current
- Electrolyte abnormalities
* HypoK/Na/Phos - Illicit Drugs
* Opiates/Sympathomimetics - Post-CPR
- Medications
* Succinylcholine
* Statins, Fibrates, Antipsychotics - Infections
- Metabolic myopathies
- Connective tissue disorders
- Rheumatologic disorders
* Polymyositis, dermatomyositis, Sjogren’s
* SLE - Hypothyroidism
- Biologic toxins
* Snakebite, African honey bee
What are the clinical effects of hypermagnesemia?
>1.6 mmol/L
- Muscle weakness, hyporeflexia
- Nausea and vomiting
- Hypotension secondary to vasodilation
>4.0 mmol/L
- Coma
- Hypoventilation
- Neuromuscular Paralysis
- Cardiac arrhythmias, bradycardia and death
Outline your treatment of DKA, with specific doses and goals
1. Resuscitation
- NS 10 cc/kg, repeated until not in shock
2. Fluid Resuscitation
- NS 250 cc/hr
- Add KCl once K < 5 mmol/L AND patient has UOP
- Change to D5½NS once BG drops to 15 mmol/L
3. Insulin
- Insulin R 0.1 units/kg/hr IV
- No bolus
- Stop when AG normal
Goals of DKA Treatment:
- Correct metabolic acidosis
- Correct electrolyte abnormalities
- Identify and Tx underlying trigger
What are your FIVE priorities in managing a thyroid storm?
- Block conversion of T4-T3 (Steroids, Propanol, PTU)
- Block release of thyroid hormone (iodide)
- Block the adrenergic effects (beta-blockers)
- Block production of thyroid hormone (PTU/Methimazole)
- Supportive care
- Find inciting event
List 6 causes of diabetes insipidus
Central
- Trauma
- Malignancy
- Pituitary surgery
- SAH
Nephrogenic
- Renal disease
- Medications (lithium)
- Genetic disorders
Pathophysiology
ADH causes free water reabsorption. If lacking or ineffective, you void very dilute urine.
List complications associated with IV NaHCO3 therapy
- Paradoxical CNS acidosis
- Impaired oxygen delivery
- Hypokalemia
- Hypocalcemia
- “Overshoot” alkalosis
- Hypernatremia
- Volume overload
- Hyperosmolality
Name the scoring system for diagnosis of thyroid storm
What are the six elements of this scoring system?
Burch-Wartofsky Score
“Thyroid Problems Make Fatties Go Crazy”
- Tachy
- Precipitating event
- Mental status
- Fever
- GI/hepatic
- CHF
>45 points definitive
25-44 maybe
<25 prob not
Explain the Somogyi phenomenon
High blood sugar in AM misinterpreted as not enough insulin at PM when actually they are hypoglycemic in PM and the hyperglycemia in the AM is from counterregulatory hormones.
List 3 types of hypernatremia and examples of each. How do you calculate free water deficits?
Hypovolemia
- Check urine sodium
- Low = Not drinking, critically ill, extrarenal loss
- High = Diuretic
Euvolemic
- Urine Na High = Dehydrated
- Urine Na Low/normal = Diabetes Insipidus
Hypervolemic - Don’t need to measure the Urine
- Salt poisoning
- Primary Hyperaldosteronism (Conn’s)
- Formula misfed babies
Water Deficit = [weight (kg) x 0.6] x [(Na level – 140) / 140]

List 6 causes of SIADH
- Cancers: Small cell lung cancer
- Infections: TB, Pneumonia
- SAH
- Head trauma
- Pain
- Nausea
- Meningitis
- Meds (SSRI, Haldol, Opioid, Antineoplastics)
List FOUR causes of hypothyroidism
- Hashimoto’s
- Neonatal
- Drugs (Lithium, Amiodarone)
- Central cause
- Sheehan
- Iodine deficiency
List 8 causes of hypocalcemia
- Hypoalbuminemia
- Hyperphosphatemia
- Hypomagnesemia
- Hypoparathyroidism
- Vit D deficiency
- Respiratory alkalosis
- Rhabdomyolysis
- Tumour lysis syndrome
- Massive transfusion
- Hydrofluoric acid
- Renal failure
List SIX ECG features of hypokalemia
- Prolonged QT
- T wave flattening/inversion
- ST depression
- U wave
- AV Block
- Ectopy (PVCs)
- Arrhythmias (Afib, Vfib, asystole)
List 6 causes of hypomagnesemia
- Alcoholics/malnourished/cirrhosis
- Pancreatitis
- GI losses – Laxatives, diarrhea, Crohn’s, UC
- DKA – large diuresis from glucosuria
- Renal losses
* Diuretics
* Aminoglycosides - Nephrotoxic chemotherapy
- PPI use
- Digoxin
- HF toxicity
- Bartter’s Syndrome
How does the urinary sodium concentration help in the diagnosis of euvolemic hyponatremia?
Euvolemic hyponatremia
UNa+ > 20mEq/L
- Endocrinopathy (AI)
- SIADH causing drugs
- SIADH >100
UNa+ < 10mEq/L
- Polydipsia
List 6 causes of hypokalemia
- Loop diuretics (HCTZ/Furosemide)
- NS administration
- Diet
- RTA 1/2
- GI losses
- Sweating
- Malnutrition
Compare and contrast HHS and DKA
HHS
- Glucose is comically high >33
- Not very acidotic pH >7.3
- They’re many liters down (higher BUN)
- They don’t have ketones in their urine
DKA
- Hyperglycemia but usually < 33
- Acidotic
- Dehydrated less (still high BUN)
- Ketones
Which TWO drugs should you AVOID in thyroid storm?
- ASA
- NSAIDs
* These displace thyroid hormone from thyroglobulin - Amiodarone
- Contrast dye
* These have a high iodine load
Outline your management of a glyburide overdose. How long should they be observed?
- Charcoal, if safe/indicated
- POCT Glucose q1h until stable
* D50 IV push, if hypoglycemic - Dextrose infusion
- Octreotide 50-100 mcg IV q12h
* Only if hypoglycemic - Observe for 24 hours
What are TWO features in a patient with Addison’s disease (primary AI) but NOT secondary AI?
-
Hyperpigmentation
* Primary AI results in high ACTH
* MSH is released with ACTH
* ACTH also binds the MSH receptor -
Hypotension
* Aldosterone more affected in primary
What are the types of RTA?
Type I – Distal RTA
- Failure of H+ excretion (H+/K+ antiporter)
- Acidemia and hypokalemia
- Get urinary stones, nephrocalcinosis, and bone demineralization
Type II – Proximal RTA
- Failure to reabsorb bicarb
- Metabolic acidosis
- Fanconi syndrome
Type IV – Hypoaldosteronism
- Impaired ammonium (NH4) excretion
- Metabolic acidosis
- Hyponatremia, hyperkalemia (opposite of Conn’s)
Type III is historical and was a combination of I and II. Only seen in children and never again.
What are the typical diagnostic criteria for DKA?
Diagnosis
- pH <7.3 or Bicarb <18
- Ketones (elevated AG)
- Glucose >11.1
List 6 causes of Non-AG metabolic acidosis
HARDUP
- Hyperchloraemia
- Acetazolamide, Addison’s disease
- Renal tubular acidosis
- Diarrhea, ileostomies, fistulae
- Ureteroenterostomies
- Pancreatoenterostomies
How is serum calcium altered by the albumin level?
Every 10 decrease in albumin is a decrease of 0.2 calcium
What is your management of severe hypermagnesemia?
- Stop infusion of Mg (if running)
- 2 amps Calcium gluconate
- Dilution with IV NS
- Lasix
- Dialysis
List EIGHT causes of thyrotoxicosis
- Grave’s
- Excess Iodine
- Autoimmune thyroiditis
- Hashimoto’s
- Multinodular goiter
- Toxic adenoma
- Follicular cell carcinoma
- Pituitary tumour
- Teratomas/Hydatidiform moles
- Amiodarone
Walkthrough the Renin-Angiotensin-Aldosterone System and how the body responds to a decreased intravascular volume
- Juxtaglom cells sense less blood flow and release renin
- Renin causes the release of angiotensin 1 from the liver
- Angiotensin I converted to Angiotensin II in the lungs
- causes smooth muscle contraction
- causes adrenals to secrete aldosterone
- causes the pituitary to secrete ADH
- Aldosterone causes Na+ retention and K+ excretion
A 70 kg patient is seizing with a Na of 110. What is your treatment? How much do you think it will correct?
3% saline 100 cc over 10 min IV q10min until not seizing
Each 84 cc will raise the Na by 1 mEq/K
- Multiply body water by 2 to get cc of 3% saline to raise 1
- 70 kg * 0.6 = 42
- 42 * 2 = 84 cc 3% saline
What are FIVE treatment goals with myxedema?
- Replace fluids
- Replace electrolytes
- Check a glucose
- T4 300mcg IV
- Warm them
- Hydrocortisone 100mg IV
- Antibiotics because they’re likely septic
What is normal serum pH, pCO2 and HCO3?
- pH = 7.35-7.45
- pCO2 = 35-45 mmHg
- HCO3 = 22-29 mmol/L
What is a normal compensatory response for the following?
- Metabolic acidosis
- Metabolic alkalosis
- Respiratory acidosis
- Respiratory alkalosis
Metabolic Acidosis
- 1 loss in bicarb = 1 drop in CO2
Metabolic Alkalosis
- 1 increase in bicarb = 0.5 increase in CO2
Respiratory Acidosis
- 10 increase in pCO2 = 1 increase in HCO3
Respiratory Alkalosis
- 10 loss in pCO2 = 2 loss in HCO3
What are the clinical features of hypercalcemia?
Bones, Stones, Groans, Psychic Moans
- Stones (Renal calculi)
- Bones (Osteolysis)
- Moans (Abdominal pain, N/V, constipation)
- Groans (PUD, pancreatitis)
- Psychiatric overtones (Psychosis, depression)
Give a reason for a falsely elevated AG
Low levels of unmeasured cations:
- Hypomagnesemia
- Hypocalcemia
- Hypokalemia
List three types of hyponatremia and an approach to each
Hypovolemic
- Urine Na Low = GI loss, Third spacing, Pancreatitis, Burns
- Urine Na Normal/High = Diuretics
Euvolemic
- Urine Na Normal/High >40 = SIADH, AI, Hypothyroidism
- Urine Na Low = Polydipsia, Beer potomania
Hypervolemic
- Cirrhosis
- CHF
- Renal failure

List 4 metabolic/endocrine abnormalities expected with primary adrenal insufficiency
The adrenal gland makes:
- Salt (Aldosterone)
- Sugar (Cortisol)
- Sex (DHEA)
Primary AI
- Hyponatremia
- Hyperkalemia
- Hypoglycemia
- Acidosis
- Hypercalcemia
How is osmolality calculated?
Osmolality = 2(Na) + Sugar + BUN + 1.25(EtOH)
2 salts and a sticky BUN + 1.25(EtOH)
List the MOA of each of these drugs:
- A. Biguanides
- B. Sulfonylureas
- C. Thiazolidinediones
- D. Meglitinides
- E. Dipeptidyl peptidase 4 inhibitors
- F. SGLT-2 Inhibitors
A. Biguanides (Metformin)
- Decreases hepatic glycogenolysis
B. Sulfonylureas (Glyburide)
- Causes insulin release
C. Thiazolinediones (Rosiglitazone)
- Increase sensitivity to insulin
D. Meglitinides (Repaglinide)
- Post-prandial insulin release
E. Dipeptidyl peptidase 4 (DPP4) inhibitors (Januvia)
- Decrease insulin degradation
F. SGLT-2 Inhibitors (Dapagliflozin - Invokana)
- Decreased glucose reuptake in kidney
List steps in the management of rhabdomyolysis
Volume Resuscitation
- NS 2L IV then give bicarb
- Target urine output is 3cc/kg/hr
Urine Alkalization
- Only if CK >5,000
- Bicarb infusion
- Target urine pH > 6.5 and serum pH 7.4-7.45
- Not evidence-based
- Discontinue if hypocalcemia, pH>7.5, or bicarb >30
Mannitol
- 1 g/kg over 30 min then 5 g/h IV (120 g/day)
- Controversial
- Monitor osmol gap – stop if >55mOsm/kg
Renal Replacement Therapy
- Indicated for:
- Persistent acidosis
- Volume overload
- Hyperkalemia (not responding)
- Oliguria/Anuria despite fluids
List 6 causes of hypermagnesemia
- Iatrogenic
- Laxatives (Magnesium oxide)
- Antacids
- Dialysate
- Bowel obstruction
- Anticholinergics
- Narcotics
- Lithium
- Hypothyroidism
- TLS
- Adrenal insufficiency
List SIX causes of respiratory acidosis
Causes of inability to breath off CO2
- COPD
- Pneumonia
- Asthma
Decreased LOC
- TBI
- Brain bleed
- Opioids
Neuromuscular weakness
- Myasthenia
- C-spine injury (C3/4/5)
- Guillain Barre
What are the four goals of treatment in myxedema coma?
- Correct electrolytes
- Supportive care for the patient
- Correct underlying condition
- Correct thyroid
A lot are adrenal suppressed as well
Provide a formula to estimate how much hypertonic saline is needed to raise the serum sodium by 1 mEq/L.
- 3% saline has 513 mmol/L of sodium
- ~0.5 mmol/mL or 1 mmol/2 mL
- TBW = 60% of body weight
- So, if you multiply TBW by 2, that’s the amount in mL
Example
- A 120 kg man has 120 * 0.6 = 72 L of water
- 72 * 2 = 144 cc 3% saline would raise Na by 1 mmol/L