EM E2: Endocrine

What glucose level defines hypoglycemia?

< 50-60 mg/dL

What are RF for hypoglycemia?

diabetic medical therpay, inadequate food intake, inc physical activity, polypharmacy, ethanol use, sepsis

What are sx of hypoglycemia?

anxiety, nervousness, irritability, N/V, palpitations, tremor, CNS dysfunction or mild AMS

What is the preferred test for hypoglycemia?

bedside glucose monitoring -immediate

What is the tx for hypoglycemia?

Dextrose 1g/kg as D50 then D10W for maintenance

oral replacement (total of 300g of carbs)

Glucagon 1mg IM or IV (will not help alcoholics, elderly, or others w/ depleted glycogen stores)

monitor bedside glucose q30 min

What is the tx for sulfonylurea induced hypoglycemia?

Octreotide

How does type 1 diabetes frequently present?

DKA w/ acute infection or other significant stress

How does Type 2 DM present?

asx for yrs, present w/ complications of the disease (candida vaginitis or balanitis, recurrent UTI)

What are sx of T2DM?

visual changes, neuro sx, numbness, dizziness, weakness, GI/GU sx, inc thirst, slow wound healing, paresthesia

What is considered prediabetic?

fasting plasma glucose >110 but < 126

Is it reasonable to test blood glucose in pts presenting to the ED w/ unexplained cellulitis, foot ulcers, frequent candidal infections and unexplained neuropathy?

yes -suspicious for diabetes

What is the tx for acute hyperglycemia?

volume restoration, tx underlying cause

What is the criteria of HHNS?

serum glucose > 600 mg/dL, plasma osmolality > 315, serum bicarbonate > 15, arterial pH > 7.3, negative or few ketones

What are sx of HHNS?

weakness, anorexia, fatigue, cough, dyspnea, abd pain, poorly controlled T2DM, CNS sx

What are RF for HHNS?

noncompliance, under-dosing insulin, baseline cognitive impairment, impaired means of communication, limited access to free water intake, use of diuretics

Other than DM, what are other causes of HHNS?

CVA, severe burns, MI, infection, pancreatitis, other acute illness

What is the tx for HHNS?

correct hypovolemia (IV NS), tx precipitating causes, correct electrolyte abnormalities, gradual correction of hyperglycemia and osmolarity (insulin)

What are sx of DKA?

BG > 250, ketones, wide anion gap, metabolic acidosis, inc ventilatory response, N/V, abd pain, AMS, coma

What are RF for DKA?

omission of daily insulin, idiopathic, stressful events (infection, MI, CVA, trauma, pregnancy, hyperthyroidism, pancreatitis, pulm ebolism, surgery, steroid use

What is the tx for DKA?

aggressive fluid (1-3 L isotonic saline w/in 1st hr), fix volume first, then insulin ± potassium, phosphate, magnesium, bicarbonate

What complications can arise from tx DKA?

hypoglycemia, hypokalemia, hypophosphatemia, ARDS, cerebral edema

What is wide-anion-gap acidosis most often associated w/?

acute cessation of alcohol consumption after chronic use (alcoholic ketoacidosis)

What are sx of AKA?

N/V, abd pain, gastritis, pancreatitis, tachycardia, rarely mental status changes

What are lab findings of AKA?

elevated anion gap (essential for dx), alcohol levels low or undetectable, mild hyponatremia, hypokalemia; elevated LFTs, bilirubin, BUN, Cr

What is the tx for AKA?

fluid of choice is D5NS, administer gluocse, bicarb if pH < 7, multivitamins, IV Thiamine

What is the MCC of hyperthyroidism?

Grave’s disease

What medications can induce a thyroid storm?

iodine, lithium, thyroid meds

What are classic markers of a thyroid storm?

fever, tachycardia out of proportion to fever, GI sx, changes in normal mental status (confusion, delirium, coma)

What scale is used for thyroid storm?

Burch-Wartofsky Point scale

What is the tx for a thyroid storm?

stabilize, ABC’s IVFs → BBs (propranolol), PTU or methimazole, electrolyte replacement, do NOT administer iodine until later

Euthyroid → radioiodine

What causes primary hypothyroidism?

AI -Hashimoto’s, idiopathic, iodine deficiency, after ablative therapy

What is the tx for hypothyroidism?

thyroxine

What is a myxedema coma?

rare clinical state d/t long-standing preexisting hypothyroidism w/ life-threatening decompensation

What are precipitating causes of a myxedema coma?

infection or cold exposure, drugs (sedative, lithium, amio), trauma, stroke, CHF, inadequate thyroid replacement

What are sx of a myxedema coma?

AMS, hypothermia, bradycardia, hypoventilation, CV collapse

What is the tx for a myxedema coma?

ABCs, IVFs, correct hypothermia, IV levothyroxine (alt T3), glucocorticoids, hyponatremia → hypertonic saline

How much adrenal gland must be destroyed for insufficiency to occur?

90%

What causes primary adrenal insufficiency?

AI (Addison’s)

What are sx of an adrenal crisis (life-threatening)?

hypotension resistant to catecholamine and IVF, hemorrhage or thrombosis of glands → abd and flank pain w/ hypotension; may mimic ruptured AAA

What AM cortisol levels rule in/out adrenal insufficiency?

rule in: < 83; rule out: > 525

*use short corticotropin test to exclude AI

What is the tx for an adrenal crisis?

rescue dose of corticosteroids (mandatory) → IV hydrocortisone

What are sx of Pheochromocytomas?

severe HTN, palpitations, HA, sweating, anxiety

What are complications of Pheocromocytoma HTN crisis?

MI, arryhthmias, CVA, pulm edema

What lab tests for Pheochromocytomas?

24 hr urine catecholamine, plasma metanephrines

What is the tx of a Pheochromocytoma?

pre-op: alpha blockers (phenoxybenzamine) & BB → adrenalectomy

What are sx of hyponatremia (< 125)?

N/ HA, confusion, seizures, AMS, edema, dry mucous membranes

What is the tx for hyponatremia?

hypertonic saline (3% NaCl)

*monitor for demyelination syndrome seizures