Endo Emergencies (hypoglycemia, thyroid storm, etc)

lowering, symptoms, 70, 54, 54, administer, resuscitative

Hypoglycemia General Info

• The most common acute complication of glucose-__________ therapy

• Definition

  • Episodes of an abnormally low plasma glucose concentration (with or without _________) that expose the individual to harm

• Level 1 Hypoglycemia

  • Blood glucose <__ mg/dL but > __ mg/dL

• Level 2 Hypoglycemia

  • Blood glucose level < __ mg/dL

• Level 3 Hypoglycemia

  • A hypoglycemic event that requires the assistance of another person to actively __________ carbohydrate, glucagon, or other ___________ actions

1, CGM, 54, 2, frequent, sulfonylurea

Hypoglycemia Frequency

• Type _ Diabetes

  • Average 2-5 episodes of severe hypoglycemia per year

  • Continuous glucose monitoring (___) identifies much more frequent episodes of clinically important hypoglycemia (<__ mg/dL)

• Type _ diabetes

  • Substantially less ____________ than in type 1

  • Pts with type 2 treated with insulin or ___________ are generally at higher risk than those treated with diet or other medications

meals, carbohydrate, errors, insulin, older

Hypoglycemia Risk Factors (only the underlined ones from slides)

• Delayed or missed ______ or low _____________ content of meals

• Medication _______ (eg: miscalculated doses, wrong ________ type)

• Illness

• ________ age

palpitations, anxiety, paresthesias, dizziness, confusion, coma, neuroglycopenic, neurogenic

Hypoglycemia Symptoms

• Neurogenic (autonomic) symptoms

  • Tremor

  • _________

  • __________/arousal

  • Sweating

  • Hunger

  • _________

• Neuroglycopenic symptoms

  • ________

  • Weakness

  • Drowsiness

  • __________

  • Seizure

  • _____

• Older adults and pts with longstanding diabetes may have more ___________ symptoms than ___________ symptoms

carbohydrates, 15, nasal, 15, 70, intranasally, dextrose, calibrated, glucagon

Hypoglycemia Treatment

• Reverse hypoglycemia by ingesting _____________

  • __ grams of oral glucose is typically sufficient

  • Injection and _______ spray glucagon available

  • Retest glucose after __ minutes

  • Re-treat if the glucose level is not > __ mg/dL

• Level 3 hypoglycemia (requiring assistance) → administer immediate glucagon ____________, subQ, or IM

  • Or IV ___________ if IV access

• Check that the pts blood glucose monitoring equipment is accurately ____________

• Check that the pt has a filled ___________ prescription

health, hypoglycemia, work, driving, acute, CV, dementia, falls

Hypoglycemia Consequences

• Reduced _______-related quality of life

• Diabetes distress and fear of ___________

• Increased time away from _____

• Recurrent episodes of hypoglycemia may impact __________ privileges, employment, and interpersonal releationships

• _______ hypoglycemia episodes can be life-threatening

• Increased risk of __ events and mortality

• In older adults, severe hypoglycemia has been associated with an increased risk of ___________

• Episodes of hypoglycemia may lead to episodes of dizziness or weakness in frail, older adults, increasing the risk of ______ and fracture

patterns, plans, exercise, overtreat, dementia, caregivers, CGM, 1, medications

Hypoglycemia Prevention

• Patient Education

  • How to adjust insulin doses based on glucose ____________, meal ______, and planned ___________

  • How to treat (but not _________) evolving hypoglycemia with oral carbohydrate or glucagon

  • Recurrent hypoglycemia can increase ___________ risk in elderly patients

  • ____________ should be taught how to recognize severe hypoglycemia and treat with glucagon

• Changes in Treatment Regimen

  • Wearing ___ when on insulin regimen

  • Type _ Diabetes

    • Sensor-augmented insulin pump therapy can reduce time in hypoglycemia

  • Type 2 Diabetes

    • Consider using _________ that are not associated with hypoglycemia whenever possible and simplifying or de-escalating insulin regimens

postprandial, Whipple’s, pathologic, physiologic, fasting, C, proinsulin

Hypoglycemia in Pts Without Diabetes

• Uncommon

• Can occur in the fasting or ____________ state

• ___________ Triad → Fulfillment suggests that the hypoglycemia is ___________ rather than ___________

  • Symptoms consistent with hypoglycemia

  • A low plasma glucose when symptoms are present

  • Resolution of hypoglycemic symptoms after the plasma glucose is raised

• If Whipple’s Triad is fulfilled → must take a thorough history and PE

• Testing that can be done

  • Supervised __________ → wait for hypoglycemia then draw labs

    • Insulin

    • _-peptide

    • _________

thyrotoxicosis, antithyroid, infection, iodine, childbirth

Thyroid Storm General Info

• Rare, life-threatening condition characterized by severe clinical manifestations of ___________

• Precipitating events

  • Abrupt discontinuation of __________ drugs

  • Surgery

  • Trauma

  • _______

  • Acute __________ load

  • __________

• Mortality rate of thyroid storm is 10-30%

tachycardia, hypotension, hyperpyrexia, agitation, N/V/D, abdominal, jaundice, tremor

Thyroid Storm Signs and Symptoms

• __________ → rates can exceed 140 bpm

• Congestive heart failure

• _____________

• Cardiac arrhythmia

• Cardiovascular collapse

• ___________ → 104-106 F is common

• ____________

• Anxiety

• Delirium

• Psychosis

• Stupor

• Coma

• Severe _/_/_

• ____________ pain

• Hepatic failure with __________

• Goiter

• Ophthalmopathy

• Lid lag

• Hand __________

• Warm and moist skin

fever, CNS effects, GI/Hepatic dysfunction, Tachycardia, CHF severity, atrial fibrillation, precipitating event

What are the 7 components of the Burch-Wartofsky Point Scale (BWPS) used in assessing thyroid storm?

• < 25 points = thyroid storm unlikely

• 25-44 points = impending thyroid storm (clinical suspicion needed)

• >45 points = highly suggestive of thyroid storm

hyperpyrexia, CV, biochemical, elevation, suppression, amiodarone, compliance

Thyroid Storm Diagnostics

• Diagnosis

  • The presence of severe and life-threatening symptoms (___________, __ dysfunction, altered mentation) in a pt with __________ evidence of hyperthyroidism (__________ of free T4 and/or T3 and ___________ of TSH)

• Determining the etiology

  • In a multicenter study from France, ___________ use was the most common precipitating factor

  • Check for infection, trauma, medication _____________

beta blocker, propranolol, PTU, Methimazole, hepatotoxicity, iodine, hour, hydrocortisone, dexamethasone

Thyroid Storm Management

• ____ _________ to control the symptoms, HR, and BP

  • Usually ___________

  • Contraindicated in pts with acute decompensated heart failure with systolic dysfunction

• Thionamide to block new hormone synthesis

  • ___ preferred for life-threatening thyroid storm

    • Blocks conversion of T4 to T3

  • Pts should be transitioned to ___________ before discharge from the hospital → has longer duration of action and less ___________

• __________ solution to block the release of thyroid hormone

  • Potassium iodide oral solution (SSKI) or Lugol’s solution

  • Administer one ____ after first dose of thionamide is taken

    • If taken too early, the iodine can be used as substrate for new hormone synthesis

• Glucocorticoids to reduce T4 to T3 conversion

  • Usually __________ or _____________

bile, reduce, recycling, absorption, antipyretics

Thyroid Storm → Other Treatments

• _____ acid sequestrants

  • Cholestyramine

  • Has been found to _______ thyroid hormone levels in thyrotoxic patients by interfering with enterohepatic circulation and _________ of thyroid hormone

  • Can interfere with the ___________ of other meds → take 2 hrs before or 2 hrs after, not together

• ___________ for fever

• Treat precipitating factors (infection)

hypothyroidism, high, women, infection, cold, sedative

Myxedema Coma General Info

• Severe ___________ leading to decreased mental status, hypothermia, and other symptoms related to decreased function in multiple organs

• Medical emergency with a ____ mortality rate

• Most often affects older ______

• Can occur as the culmination of severe, longstanding hypothyroidism OR be precipitated by an acute event in a poorly-controlled hypothyroid patient

  • Precipitating events → _________, MI, ____ exposure, surgery, __________ drugs

obtundation, madness, hypothermia, bradycardia, natremia, glycemia, hypoventilation, puffiness

Myxedema Coma Signs and Symptoms

• Decreased Mental Status

  • Lethargy

  • __________

  • Psychotic features (“Myxedema _______”)

• ____________

• Hypotension

• _________

• Hypo_________

• Hypo________

• ABG pattern = _____________ → hypoxia and hypercapnia

• ____________ of the hands and face

• Signs and symptoms of precipitating illness

exclusion, thermia, natremia, capnia, thyroidectomy, low, cortisol

Myxedema Coma Diagnosis

• Initially based upon the history, PE, and __________- of other causes of coma

  • The dx should be suspected in any pt with coma or depressed mental status + hypo_______, hypo_________, and/or hyper_______

  • Important clues to the possible presence of myxedema coma

    • Presence of ___________ scar

    • Hx of radioiodine therapy or hypothyroidism

• Labs

  • TSH

  • Free thyroxine (T4) → usually very ____

  • __________

    • Check bc pts may have associated hypopituitarism and secondary adrenal insufficiency or concomitant primary adrenal insufficiency

admit, mechanical, glucose, passive, hypotension, glucocorticoids, liothyronine, empiric

Myxedema Coma Treatment

• Supportive Measures

  • ______ to ICU → manage aggressively

  • _____________ ventilation if necessary

  • IV fluids including electrolytes and _________

  • __________ rewarming with a blanket for correction of hypothermia

    • Active rewarming carries a risk of vasodilation and worsening _____________

• ____________ → until the possibility of coexisting adrenal insufficiency has been excluded

• Thyroid hormone

  • Levothyroxine (T4) + ___________ (T3)

• Appropriate management of coexisting problems

  • As with any critically ill, comatose pt, ____________ antibiotics should be considered until appropriate cultures are proven negative

arrhythmias, natremia, thyroid, older, cardiac, hypothermia

Myxedema Coma Monitoring and Prognosis

• Pts should be monitored for cardiac ___________, for correction of hypo_________, and for improvement in _________ tests

• Predictors of mortality

  • _______ age

  • _________ complications

  • Reduced consciousness

  • need for mechanical ventilation

  • Persistent ___________

  • Sepsis

glucocorticoid, mineralocorticoid, infection, more, absorption, bilateral, pituitary, unmasking, Addisons

Acute Adrenal Crisis

• A life-threatening state caused by insufficient levels of ____________ and _____________

• Develops in the following situations

  • In pts with chronic primary adrenal insufficiency

    • Serious __________ or other acute major stress

    • Insufficient daily doses of glucocorticoid and or mineralocorticoid

    • Failure to take ____ glucocorticoid during and infection or other major illness

    • Persistent V/D caused by viral gastroenteritis or other GI disorders, leading to decreased __________

  • An acute cause of adrenal gland destruction, such as __________ infarction

  • Development of an acute cause of secondary or tertiary adrenal insufficiency, such as __________ infarction

  • ___________ of secondary adrenal insufficiency in pts who are abruptly withdrawn from supraphysiologic doses of glucocorticoid

  • Can be first presentation of ____________ disease

dehydration, hypotension, pain, hypoglycemia, hypo, hyper, hyper, hyperpigmentation, vitiligo

Acute Adrenal Crisis Signs and Symptoms

• Predominantly manifests as shock

  • ___________ and ______________

• Anorexia

• N/V

• Abdominal ____

• Weakness, fatigue, lethargy, confusion

• Unexplained __________

• Unexplained fever

• ____natremia, _____kalemia, _____calcemia, eosinophilia

• _____________ or __________

cortisol, ACTH, pregnant, estrogens, normal

Acute Adrenal Crisis Diagnosis

• __________ <18 mcg/dL

  • In hypotensive pt considered to be in adrenal crisis, basal serum cortisol level < 18 mcg/dL suggests the dx of AI

  • ____ stimulation testing should be done at a later date to confirm AI

• Cortisol > 18 mcg/dL

  • Adrenal insufficiency is unlikely

  • HOWEVER, some pts may have increased corticosteroid-binding globulin (CBG) levels

    • ___________ patients

    • Those taking __________

  • These pts with excessive CBG may have adrenal insufficiency even with apparently __________ cortisol values

hydrocortisone, broad, hydrocortisone, stress

Acute Adrenal Crisis Treatment

• Glucocorticoid Treatment

  • IV _____________ bolus, then continuous infusion at lower dose

• Monitor serum electrolyte and glucose levels closely

• Since bacterial infection frequently precipitates acute adrenal crisis, ______-spectrum Abx should be administered empirically while waiting for the results of the initial culture

• Once the pt has stabilized

  • Taper ____________ over 1-3 days

  • Convert to an oral ______ dose or maintenance regimen once the pt can take oral meds