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Royal College: Emergency Medicine > Metabolism & Endocrine > Flashcards

Metabolism & Endocrine Flashcards

This deck covers Chapters 116-120 in Rosens, compromising all of endocrinology, electrolyte disturbances, and acid-base physiology.

1
Q

What is Conn’s syndrome? Is the K elevated?

A

Conn’s Syndrome

  • Primary hyperaldosteronism
  • Hypernatremia
  • Hypokalemia
  • Hypertension
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2
Q

List 8 causes of hypophosphatemia

A
  1. Malnourished
  2. EtOH abuse
  3. Hyperventilation
  4. Sepsis
  5. NMS
  6. Insulin
  7. Diuretics
  8. Burns
  9. Hyperparathyroidism
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3
Q

List FOUR tests that can help diagnose adrenal insufficiency

A

To Diagnose

  1. AM Cortisol
  2. AM ACTH
    * Differentiates 1* from 2* (1* = high ACTH)
  3. 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
  4. 24h Urine for 17-OH Steroids

If in doubt re: diagnosis, give dexamethasone because hydrocortisone has mineralocorticoid activity.

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4
Q

List SIX causes of a high osmolar gap

A
  1. EtOH
  2. Methanol
  3. Isopropyl Alcohol
  4. Ethylene Glycol
  5. DKA
  6. Mannitol/Sorbitol
  7. Hyperlipidemia
  8. CKD
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5
Q

Outline your management of hypercalcemia in the ED

A
  1. Fluids, fluids, fluids
  2. Diuretics are contentious: if you give any, make it Lasix
  3. Bisphosphonates
  4. Calcitonin 4 IU/kg
  5. Hydrocortisone (if granulomatous dz, not cancer)
  6. Remove offending agent/treat underlying condition
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6
Q

What is the formula for the anion gap? What is the correction for albumin?

A

Anion Gap

  • Na+ - (HCO3- + Cl-)

For every 10 g/L drop in albumin remove 2.5 from expected AG

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7
Q

How would you approach severely symptomatic hyponatremia and how quickly would you correct the serum sodium?

A

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
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8
Q

How can the measured sodium in patients with hyperglycemia be corrected?

A

↑ Glucose 10 mmol/L causes ↓ Na+ 3 mmol/L

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9
Q

Differentiate activated hyperthyroidism from unactivated (apathetic) hyperthyroidism

A

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
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10
Q

Differentiate primary and secondary adrenal insufficiency. List FIVE causes of each.

A

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
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11
Q

List SIX causes of increased ADH

A

​SIADH and Normal

  1. Increased osmolarity (Na+)
  2. Decreased BP
  3. SAH
  4. Pain
  5. Medications (SSRI)
  6. Low pressure, low volume
  7. Caffeine
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12
Q

The anion gap takes into consideration chloride and bicarb. What are FIVE classic unmeasured anions?

A
  1. Albumin
  2. Lactate
  3. Ketones
  4. Sulfate
  5. Phosphate
  6. Organic acids
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13
Q

What is the pathophysiology of rhabdomyolysis?

A
  • 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
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14
Q

List the 6 progressive ECG changes of hyperkalemia

A
  1. Peaked T waves
  2. Loss of P waves
  3. Widening of QRS
  4. Sine wave
  5. Vfib
  6. Asystole
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15
Q

List 6 causes of hyperkalemia

A
  1. Hemolysis
  2. Renal failure
  3. Drugs (Spironolactone, ACEi, NSAIDs)
  4. Tumour lysis syndrome
  5. Rhabdomyolysis
  6. Digoxin toxicity
  7. Amiloride
  8. Iatrogenic
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16
Q

Give FOUR causes for falsely low anion gap

A

High levels of unmeasured cations:

  1. Lithium
  2. Hypergammaglobulinemia (MM)
  3. Hypertriglyceridemia
  4. Bromide toxicity
  5. Hypoalbuminemia
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17
Q

List SIX triggers for DKA

A

The 8 “I’s”

  1. Initial
  2. Insulin non-compliance
  3. Infarct (MI/CVA)
  4. Infection
  5. Incision (surgery)
  6. Insemination (pregnancy)
  7. Intoxication
  8. Iatrogenic (medication changes)
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18
Q

List SIX symptoms consistent with thyrotoxicosis

List SIX signs consistent with thyrotoxicosis

A

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

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19
Q

In regards to the serum glucose, how is diabetes diagnosed?

A
  • Random plasma glucose >11.1 mmol/L
  • Fasting plasma glucose >7 mmol/L
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20
Q

List 6 drugs that have been associated with rhabdomyolysis

A
  1. Barbiturates
  2. Benzodiazepines
  3. Colchicine
  4. Corticosteroids
  5. Isoniazid
  6. Lithium
  7. MAOIs
  8. Narcotics
  9. Neuroleptics
  10. Phenothiazines
  11. Salicylates
  12. Serotonergics
  13. Statins
  14. Theophylline
  15. TCAs
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21
Q

List EIGHT causes of respiratory alkalosis

A

Central

  1. Head Injury
  2. Stroke
  3. Anxiety
  4. Pain
  5. ASA
  6. Pregnancy
  7. High-altitude
  8. Anemia

Pulmonary

  1. Hypoxia
  2. PE
  3. Pneumonia
  4. Asthma
  5. Pulmonary edema
  6. Mechanical ventilation
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22
Q

Explain the phenomenon of paradoxical worsening of ketosis as AKA/DKA is treated.

A
  • 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
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23
Q

List TEN causes of hypercalcemia

A

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
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24
Q

What is the management of hyponatremia in the asymptomatic or mild-mod symptomatic patient?

A

Hypovolemic hyponatremia

  • NS 0.9% to correct deficit

Euvolemic hyponatremia

  • Free-water restriction

Hypervolemic hyponatremia

  • Free-water restriction and diuresis +/- dialysis
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25
Q

List SIX causes of metabolic alkalosis

A

CLEVER PD

  • Contraction
  • Licorice
  • Endocrine (Conn’s, Cushing’s)
  • Vomiting
  • Excess alkali (Antacids)
  • Refeeding/Renal
  • Post-hypercapnia
  • Diuretics
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26
Q

When would you treat hyponatremia acutely?

A

Both of:

  1. Sodium <120 mEq/L
  2. Altered, focal neuro deficits, or seizing

Treatment

  • 3% saline 100 cc IV over 15 minutes (raises Na 2-3 mEq)
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27
Q

List 5 precipitants of myxedema coma

Who is the typical patient that will present with myxedema coma? What will their vitals be like?

A

Precipitants

  • Infection
  • Infarction
  • Incision (Surgery)
  • GI bleed
  • Hypoglycemia
  • Hypothermia
  • Medications

Typical Patients

  • Older women
  • Thyroidectomy

Vitals

  • Hypothermic
  • Bradycardic
  • Hypotensive
  • Altered
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28
Q

What are the ECG changes in hypocalcemia?

A
  • Short PR
  • Long QT
  • ST depression
  • TWI
  • U wave

Arrhythmia is uncommon.

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29
Q

Describe the clinical presentation of hypocalcemia

A

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
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30
Q

How do you calculate how much hypertonic saline to administer to a patient who has severe symptoms but is not actively seizing?

A

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
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31
Q

List EIGHT causes of high anion gap metabolic acidosis

A

MUDPILES CAT

  1. Methanol/Metformin
  2. Uremia
  3. DKA
  4. Propylene glycol/Paraldehyde
  5. Iron, INH
  6. Lactate
  7. Ethylene Glycol
  8. Salicylates
  9. CO, Cyanide
  10. Alcoholic Ketoacidosis
  11. Toluene
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32
Q

How is acid sensed in the body? How is H+ maintained?

A

pH Sensing

  • Central = Medulla
  • Peripheral = Carotid body

H+ Homeostasis

  • H/K+ renal antiporter
  • Carbonic anhydrase
  • Buffering capacity
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33
Q

What is a delta gap? How do you calculate it?

A

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
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34
Q

Define the following:

  • Wolff-Chaikoff Effect
  • Jod-Basedow Effect
A

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
35
Q

List 5 glucoregulatory hormones and describe their mechanism of action

A
  1. Insulin (ANABOLIC)
    * Augments hepatic glucose uptake and storage
    * Inhibits gluconeogenesis and glycogenolysis
  2. 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
  3. Epinephrine (CATABOLIC)
    * Increase hepatic glycogenolysis + gluconeogenesis
  4. Cortisol (CATABOLIC)
  5. ​GH (CATABOLIC)​
    * Neither cortisol nor GH are rapid glucose changers
36
Q

How do you treat suspected adrenal crisis?

A

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
37
Q

List EIGHT triggers of thyroid storm

A
  1. Infection
  2. Brain bleeds
  3. Head injury
  4. Iatrogenic (over-medicated)
  5. Amiodarone
  6. Burns
  7. Thyroid surgery
  8. Pregnancy
  9. CHF
  10. PE
  11. Hyperemesis
38
Q

How would you treat hypocalcemia in the ED?

A

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)
39
Q

How do you manage thyroid storm?

A

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
40
Q

List the 5 most common causes of hypokalemia

A

Renal losses

  • Diuretics

Non-renal losses

  • Vomiting
  • Diarrhea

Decreased intake

  • Malnourished
  • Alcoholism

Intracellular shift

  • Hyperventilation
  • Insulin
  • Sympathomimetics

Endocrine

  • Conn’s
  • Cushing
  • Bartter’s syndrome
41
Q

Provide FIVE causes of a “double gap” (Anion + Osmolar)

A
  1. Methanol
  2. Ethylene glycol
  3. DKA
  4. AKA
  5. Sepsis
  6. Chronic Renal failure
42
Q

How does amiodarone cause thyroid issues?

A
  • Has iodine in it
  • Structurally similar to T4
  • Can cause thyrotoxicosis
  • Directly toxic to the gland
43
Q

List EIGHT causes of rhabdomyolysis

A
  1. Prolonged immobilization
  2. Excessive exercise
  3. Muscle ischemia
  4. Temperature extremes
    * Heatstroke, NMS, MH
    * Hypothermia
  5. Electrical current
  6. Electrolyte abnormalities
    * HypoK/Na/Phos
  7. Illicit Drugs
    * Opiates/Sympathomimetics
  8. Post-CPR
  9. Medications
    * Succinylcholine
    * Statins, Fibrates, Antipsychotics
  10. Infections
  11. Metabolic myopathies
  12. Connective tissue disorders
  13. Rheumatologic disorders
    * Polymyositis, dermatomyositis, Sjogren’s
    * SLE
  14. Hypothyroidism
  15. Biologic toxins
    * Snakebite, African honey bee
44
Q

What are the clinical effects of hypermagnesemia?

A

>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
45
Q

Outline your treatment of DKA, with specific doses and goals

A

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:

  1. Correct metabolic acidosis
  2. Correct electrolyte abnormalities
  3. Identify and Tx underlying trigger
46
Q

What are your FIVE priorities in managing a thyroid storm?

A
  1. Block conversion of T4-T3 (Steroids, Propanol, PTU)
  2. Block release of thyroid hormone (iodide)
  3. Block the adrenergic effects (beta-blockers)
  4. Block production of thyroid hormone (PTU/Methimazole)
  5. Supportive care
  6. Find inciting event
47
Q

List 6 causes of diabetes insipidus

A

Central

  1. Trauma
  2. Malignancy
  3. Pituitary surgery
  4. SAH

Nephrogenic

  1. Renal disease
  2. Medications (lithium)
  3. Genetic disorders

Pathophysiology

ADH causes free water reabsorption. If lacking or ineffective, you void very dilute urine.

48
Q

List complications associated with IV NaHCO3 therapy

A
  1. Paradoxical CNS acidosis
  2. Impaired oxygen delivery
  3. Hypokalemia
  4. Hypocalcemia
  5. “Overshoot” alkalosis
  6. Hypernatremia
  7. Volume overload
  8. Hyperosmolality
49
Q

Name the scoring system for diagnosis of thyroid storm

What are the six elements of this scoring system?

A

Burch-Wartofsky Score

“Thyroid Problems Make Fatties Go Crazy”

  1. Tachy
  2. Precipitating event
  3. Mental status
  4. Fever
  5. GI/hepatic
  6. CHF

>45 points definitive

25-44 maybe

<25 prob not

50
Q

Explain the Somogyi phenomenon

A

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.

51
Q

List 3 types of hypernatremia and examples of each. How do you calculate free water deficits?

A

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]

52
Q

List 6 causes of SIADH

A
  1. Cancers: Small cell lung cancer
  2. Infections: TB, Pneumonia
  3. SAH
  4. Head trauma
  5. Pain
  6. Nausea
  7. Meningitis
  8. Meds (SSRI, Haldol, Opioid, Antineoplastics)
53
Q

List FOUR causes of hypothyroidism

A
  1. Hashimoto’s
  2. Neonatal
  3. Drugs (Lithium, Amiodarone)
  4. Central cause
  5. Sheehan
  6. Iodine deficiency
54
Q

List 8 causes of hypocalcemia

A
  1. Hypoalbuminemia
  2. Hyperphosphatemia
  3. Hypomagnesemia
  4. Hypoparathyroidism
  5. Vit D deficiency
  6. Respiratory alkalosis
  7. Rhabdomyolysis
  8. Tumour lysis syndrome
  9. Massive transfusion
  10. Hydrofluoric acid
  11. Renal failure
55
Q

List SIX ECG features of hypokalemia

A
  1. Prolonged QT
  2. T wave flattening/inversion
  3. ST depression
  4. U wave
  5. AV Block
  6. Ectopy (PVCs)
  7. Arrhythmias (Afib, Vfib, asystole)
56
Q

List 6 causes of hypomagnesemia

A
  1. Alcoholics/malnourished/cirrhosis
  2. Pancreatitis
  3. GI losses – Laxatives, diarrhea, Crohn’s, UC
  4. DKA – large diuresis from glucosuria
  5. Renal losses
    * Diuretics
    * Aminoglycosides
  6. Nephrotoxic chemotherapy
  7. PPI use
  8. Digoxin
  9. HF toxicity
  10. Bartter’s Syndrome
57
Q

How does the urinary sodium concentration help in the diagnosis of euvolemic hyponatremia?

A

Euvolemic hyponatremia

UNa+ > 20mEq/L

  • Endocrinopathy (AI)
  • SIADH causing drugs
  • SIADH >100

UNa+ < 10mEq/L

  • Polydipsia
58
Q

List 6 causes of hypokalemia

A
  1. Loop diuretics (HCTZ/Furosemide)
  2. NS administration
  3. Diet
  4. RTA 1/2
  5. GI losses
  6. Sweating
  7. Malnutrition
59
Q

Compare and contrast HHS and DKA

A

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
60
Q

Which TWO drugs should you AVOID in thyroid storm?

A
  1. ASA
  2. NSAIDs
    * These displace thyroid hormone from thyroglobulin
  3. Amiodarone
  4. Contrast dye
    * These have a high iodine load
61
Q

Outline your management of a glyburide overdose. How long should they be observed?

A
  1. Charcoal, if safe/indicated
  2. POCT Glucose q1h until stable
    * D50 IV push, if hypoglycemic
  3. Dextrose infusion
  4. Octreotide 50-100 mcg IV q12h
    * Only if hypoglycemic
  5. Observe for 24 hours
62
Q

What are TWO features in a patient with Addison’s disease (primary AI) but NOT secondary AI?

A
  1. Hyperpigmentation
    * Primary AI results in high ACTH
    * MSH is released with ACTH
    * ACTH also binds the MSH receptor
  2. Hypotension​​
    * ​​Aldosterone more affected in primary
63
Q

What are the types of RTA?

A

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.

64
Q

What are the typical diagnostic criteria for DKA?

A

Diagnosis

  1. pH <7.3 or Bicarb <18
  2. Ketones (elevated AG)
  3. Glucose >11.1
65
Q

List 6 causes of Non-AG metabolic acidosis

A

HARDUP

  • Hyperchloraemia
  • Acetazolamide, Addison’s disease
  • Renal tubular acidosis
  • Diarrhea, ileostomies, fistulae
  • Ureteroenterostomies
  • Pancreatoenterostomies
66
Q

How is serum calcium altered by the albumin level?

A

Every 10 decrease in albumin is a decrease of 0.2 calcium

67
Q

What is your management of severe hypermagnesemia?

A
  • Stop infusion of Mg (if running)
  • 2 amps Calcium gluconate
  • Dilution with IV NS
  • Lasix
  • Dialysis
68
Q

List EIGHT causes of thyrotoxicosis

A
  1. Grave’s
  2. Excess Iodine
  3. Autoimmune thyroiditis
  4. Hashimoto’s
  5. Multinodular goiter
  6. Toxic adenoma
  7. Follicular cell carcinoma
  8. Pituitary tumour
  9. Teratomas/Hydatidiform moles
  10. Amiodarone
69
Q

Walkthrough the Renin-Angiotensin-Aldosterone System and how the body responds to a decreased intravascular volume

A
  • 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
70
Q

A 70 kg patient is seizing with a Na of 110. What is your treatment? How much do you think it will correct?

A

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
71
Q

What are FIVE treatment goals with myxedema?

A
  1. Replace fluids
  2. Replace electrolytes
  3. Check a glucose
  4. T4 300mcg IV
  5. Warm them
  6. Hydrocortisone 100mg IV
  7. Antibiotics because they’re likely septic
72
Q

What is normal serum pH, pCO2 and HCO3?

A
  • pH = 7.35-7.45
  • pCO2 = 35-45 mmHg
  • HCO3 = 22-29 mmol/L
73
Q

What is a normal compensatory response for the following?

  • Metabolic acidosis
  • Metabolic alkalosis
  • Respiratory acidosis
  • Respiratory alkalosis
A

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
74
Q

What are the clinical features of hypercalcemia?

A

Bones, Stones, Groans, Psychic Moans

  • Stones (Renal calculi)
  • Bones (Osteolysis)
  • Moans (Abdominal pain, N/V, constipation)
  • Groans (PUD, pancreatitis)
  • Psychiatric overtones (Psychosis, depression)
75
Q

Give a reason for a falsely elevated AG

A

Low levels of unmeasured cations:

  1. Hypomagnesemia
  2. Hypocalcemia
  3. Hypokalemia
76
Q

List three types of hyponatremia and an approach to each

A

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
77
Q

List 4 metabolic/endocrine abnormalities expected with primary adrenal insufficiency

A

The adrenal gland makes:

  • Salt (Aldosterone)
  • Sugar (Cortisol)
  • Sex (DHEA)

Primary AI

  • Hyponatremia
  • Hyperkalemia
  • Hypoglycemia
  • Acidosis
  • Hypercalcemia
78
Q

How is osmolality calculated?

A

Osmolality = 2(Na) + Sugar + BUN + 1.25(EtOH)

2 salts and a sticky BUN + 1.25(EtOH)

79
Q

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

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
80
Q

List steps in the management of rhabdomyolysis

A

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
81
Q

List 6 causes of hypermagnesemia

A
  1. Iatrogenic
  2. Laxatives (Magnesium oxide)
  3. Antacids
  4. Dialysate
  5. Bowel obstruction
  6. Anticholinergics
  7. Narcotics
  8. Lithium
  9. Hypothyroidism
  10. TLS
  11. Adrenal insufficiency
82
Q

List SIX causes of respiratory acidosis

A

Causes of inability to breath off CO2

  1. COPD
  2. Pneumonia
  3. Asthma

Decreased LOC

  • TBI
  • Brain bleed
  • Opioids

Neuromuscular weakness

  • Myasthenia
  • C-spine injury (C3/4/5)
  • Guillain Barre
83
Q

What are the four goals of treatment in myxedema coma?

A
  1. Correct electrolytes
  2. Supportive care for the patient
  3. Correct underlying condition
  4. Correct thyroid

A lot are adrenal suppressed as well

84
Q

Provide a formula to estimate how much hypertonic saline is needed to raise the serum sodium by 1 mEq/L.

A
  • 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

Royal College: Emergency Medicine (25 decks)

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