Endocrinology Emergency (Diagnosis / Treatment)- Hypoglycemia
- Rule of 15
- If Glucose < 70 mg / dl : 15 gm of CHO
- If < 50 : 30 gm of CHO
- Acceptable CHO choices = 15 gm of CHO
- 4 glucose tab
- 1/2 cup (4 oz) of juice or regular soda
- 1 Tablespoon of sugar
- Recheck in 15 min; retreat if <70 mg / dl
- if > 70, and meal will not be provide in 30 min, give a snack of graham crackers / peanut butter or milk (slower acting CHO the will keep glucose at goal)
- If patient is unresponsive:
- 1/2 - 1 amp of D50 % Or
- 1 mg of Glucagon 1 mg SC or IM, feed after waking up
- DKA
- Low insulin
- Fat: Lipolysis: FFA (goes to liver for Ketoacidosis, and Glycerol (goes to liver for gluconeogenesis)
- Protein
- Glucose: Hyperglycemia (usually > 250)
- If < 250, think of
- alcoholic ketoacidosis
- starvation ketoacidosis
- Partially treated DKA (insulin will drop glucose down quickly)
- Ketoacids
- Acetone
- Acetoacetone
- B - Hydroybutyrate
- Treatment: Only REGULAR Insulin
- Continue IV Insulin until
- Acidosis is clear (ideally if no urine ketones, that is the end of the need of IV insulin)
- So, Monitor HCO3-, CO2, and Anion Gap
- Potassium supplement can be started if good urine output, even if K 4 - 5.
- HCO3 : pH < 6.9, otherwise do not give. Given as a drip over 30 min (not as a bolus)
- HHS
- Osmolality > 320, Glucose > 600
- Rapid drop in blood glucose will put them at risk of cerebral edema
- Ketone will be in trace (1+ in Urine)
- Adrenal Crisis
- Clinical Suspicion is the key
- Hypotension, Electrolyte abnormalities (hyperkalemia, hyponatremia, hypoglycemia, Azotmia)
- Patient on anti-coagulation, Trauma, Septic,
- Draw Lab and Treat is the key; DO NOT WAIT UNTIL THE RESULTS ARE BACK
- if low blood glucose: add cortisol and ACTH to that sample
- Low blood glucose should increase CRH, ACTH, Cortisol
- ACTH if high will tell it is primary adrenal failure
- (Primary Adrenal Failure: Most cases aldosterone production is also impaired)
- Give Dexamenthasone 4 mg IV (does not interfere with assays) over 1 - 5 min and every 12 hrs after that.
- If known adrenal insufficiency, 100 mg of IV hydrocortisone can be given
- Then 50 - 60 microgram q6 - q8 h
- 2- 3 l of NS or 5 % Dextrose in NS as quickly as possible
- Dynamic testgin
- CRH (250 microgram- check 30 min, and 60 min)
- In primary adrenal failure, start fludocortisone, 0.1 mg by mouth daily, when NS infusion is stopped.
- Myxedema (severe hypothyroidism) Coma (altered mental status)
- Clinical Features:
- Hypo ventilation
- Hypo natremia
- Hypo thermia
- Hypo Metabolism of drugs
- Hypo Response to infection . Thus, precipitates infection
- Hypo glycemia
- Hypo adrenocortisim
- Hypo motility
- Hypo thyroidism
- Hypo mentation
- Hypo Heart Rate
- Hypo tension
- Goldstein's Sign
- Thyroid Storm
- Impending Storm
- Thyroid Storm :
- Score of 45 or more is highly suggestive of thyroid storm
- 25 - 44: Supports the diagnosis
- < 25: unlikely
- Reference:
- Thyroid Storm. Endocrinol Metab Clin North Am 1993; 22:263
- Treatment
- Inhibit Synthesis:
- PTU in HIGH dose interferes with T4 - T3 conversion, so, PTU is preferred over Methimazole
- PTU (200 mg every 4 hr is the starting dose)
- Methimazole 20 mg every 6 hr
- High dose Steroids.
- 100 mg hydrocortisone Q6H
- Will also inhibit T4 - T3 conversion
- Inhibit Release: Iodine
- 1-2 hr after PTU or Methimazole
- Formation of Methimazole.
- Block symptoms: BB to adjust the heart rate
- High dose BB also inhibits T4 - T3 conversion
- Others
- Tylenol for fever (NO ASPRIN)
- Cholestrymine
- Binds to hormones hepatoenteric circulation and decreases T4
- Hypocalcemia
- 2 tests
- PTH
- Magnesium: Mag > 0.8 is the key
- Calcitriol and Calcium (if hypoparathyroidism)
- Hypercalcemia
DM- Pathogenesis: Glucose regulation is done at
- Intake: decrease sugar intake
- Gastric Emptying Rate: GLP 1 agonist, DDP IV inhibitor
- Carbohydrate breakdown: Alpha glucosidase inhibitor
- Hormonal Release
- Insulin (B -cell)
- 3 target organ
- 1. Liver
- Glycogenesis
- Blocks Lipolysis
- Blocks Gluconeogenesis
- All these will lead to decreased liver glucose production
- 2. Adipose Tissues
- Increased Lipogenesis
- Decreased Lipolysis
- Increased glucose uptake
- 3. Muscle
- Glucagon (alpha cell)
- Amylin (B - cell)
- 3 action:
- 1. decrease glucagon
- 2. delays gastric emptying
- 3. decrease appetite
- Incretin (Intestinal Secretion; Distal Intestine secrete Incretin)
- 4 action (Amylin + Increased insulin release)
- Incretin effect: Difference in the blood glocse
- Kidney: SGL2 Inhibitor
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