Endo Emergency and Misc

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 
            • Increased uptake 
      • 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 



Recent Publications in Endocrinology
Comments