Diabetic and Endocrine Emergencies

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Diabetic and Endocrine Emergencies
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Diabetes

• Type I
• Usually presents in young patients
• Genetic, autoimmune, and/or viral factors cause
  pancreatic beta islet cell destruction leading to
  insulin deficiency
• Hyperglycemia occurs and can progress to
  ketoacidosis if insulin isnt given
• Symptoms are polyuria, weight loss, fatigue

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Diabetes

• Type II
• Occurs in older adults
• Insulin production may be OK, but the cells are
  insulin resistant
• Has genetic ties, but diet and obesity determine
  the age of onset
• Treated with diet, oral hypoglycemics, and
  insulin
• Other causes of diabetes malnutrition,
  pancreatitis, endocrine dx, steroid use

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Diabetes

• Stress-induced hyperglycemia
• Can occur in any critically ill patient
• Tight control of blood sugar with insulin
  improves survival
• Hypoglycemia
• Occurs when BS is lt70ish
• Suspect in any patient with a sudden change in
  mental state or neurologic fx
• Can be caused by a problem with diabetic tx
• Can also be caused by a variety of other
  conditions
• Malnutrition
• Systemic dx (liver dx, sepsis, infection,
  hypothermia, adrenal failure, hypopituitarism)
• Poisoning/drug toxicity
• Insulin-secreting tumors

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Diabetes

• Hypoglycemia
• Clinical features
• Tremor/sweating
• Progressive confusion
• Seizures
• Coma/irreversible neurologic damage
• Treatment
• Glucose drink or carb snack if conscious
• IV glucose if unconscious

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Diabetes

• Diabetic ketoacidosis
• Occurs with type I diabetes usually from
  infection, MI, or pancreatitis
• Insulin deficiency prevents the cells from taking
  glucose upthe kidneys excrete glucose as it
  builds up in the blood which takes water with
  itin the meantime, the cells begin to metabolize
  fat for energy, which produces ketoacids
• Clinical presentation hyperventilation and
  hypotension/hypoperfusion

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Diabetes

• Ketoacidosis
• Diagnosis
• Blood sugar
• Urine dipstick
• Electrolytes
• ABG
• Management
• Fluid resuscitation with NS to correct
  hypovolemia
• Insulin infusion to reduce blood sugar
• Electrolyte replacement especially potassium
• Acidosis should resolve with fluid and insulin
  therapy
• General O2, ATB, NG tube

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Diabetes

• Hyperosmolar non-ketotic coma (HONK)
• Less common than DKA but has much higher
  mortality (50)
• Occurs in elderly patients with Type II who have
  sufficienct insulin production to prevent fat
  metabolism but not hyperglycemia
• Osmotic diuresis leads to dehydration and
  hyperosmolality, but not ketoacidosis

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Diabetes

• HONK
• Clinical features anorexia, malaise, polyuria,
  weakness, confusion, seizures, coma
• Diagnosis is based on blood sugar and
  hyperosmolality
• Management
• Rehydration with NS but more gradually than with
  DKA
• Anticoagulants to prevent dehydration-induced
  emboli
• Lactic acidosis
• Occurs in Type II diabetics treated with
  Glucophage

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Endocrine Emergencies

• Thyroid emergencies
• Thyrotoxic crisis is a life-threatening
  hypermetabolic emergency
• Precipitated by infection, surgery, diabetes,
  labor, radioiodine therapy, and iodinated
  contrast media
• Mortality is 25
• General management
• ID and tx the cause
• Correct dehydration/electrolyte abnormalities
• Avoid aspirin
• Cool the patient down/sedate to reduce agitation

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Endocrine Emergencies

• Clinical features of severe hyperthyroid
• CNS poor concentration, irritability,
  confusion, seizures, coma
• Eyes lid lag, bulging eyes
• Peripheral tremors, goiter, tachycardia,
  jaundice, NV, heart failure, atrial fib,
  diarrhea, muscle rigidity/spasm

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Endocrine

• Thyrotoxic emergency
• Specific therapy
• Beta blockers blocks effect of thyroid to
  reduce HR, HTN, fever, and tremor
• Thiourea derivatives block T4 synthesis
• Prevention of T4 release iodine solutions,
  lithium, dexamethasone

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Endocrine

• Severe hypothyroidism
• Occurs with complications to pre-existing
  hypothyroidism
• Causes hypothermia, coma, and hypotension
• Usually affects elderly females with unrecognized
  hypothyroidism or patients who fail to take
  thyroid replacements

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Endocrine

• Hypothyroidism clinical features
• CNS lassitude, apathy, coma, seizures
• Facial thin hair, puffy eyes, coarse dry skin,
  macroglossia
• Peripheral hoarse voice, goiter, bradycarida,
  weight gain, constipation, urinary retention,
  peripheral edema, bradykinesia,
  hypoventilation/hypoxia, low voltage EKG, flat T
  waves, hypoglycemia, hyponatremia

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Endocrine

• Hypothyroidism
• Management
• Rewarm patient
• Support respiratory system
• Correct hypoglycemia
• IV thyroxine (T4)
• Sick euthyroid syndrome
• Not due to a thyroid disorder
• Low T4 binding protein and altered T4 metabolism
  cause this

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Endocrine

• Adrenal emergencies
• Adrenocortical insufficiency
• Reduced cortisol (aldosterone) production by the
  adrenal cortex
• Causes
• Adrenal gland destruction
• Addisons dx
• Surgical removal
• Adrenal infarction
• Infection
• Infiltration (eg-tumors)
• Hemorrhage
• Secondary
• Pituitary damage/infarction/hemorrhage
• Sudden exogenous steroid removal

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Endocrine

• Causes of adrenal insufficiency
• Hypothalamus destruction
• Drugs
• Inhibit steroid production
• Increase hepatic metabolism
• Critical illness

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Endocrine

• Clinical presentation of adrenal
• Acute (Addisonian) crises
• Precipitated by stress in patients with
  unrecognized adrenal insufficiency, following
  sepsis, or following adrenal hemorrhage
• Pituitary infarction also presents the same way
• Apathy, hypoglycemia, hypotension, coma
• Suspect on all patients in shock if the cause is
  not apparent
• Chronic deficiency
• Fatigue, weakness, weight loss, fever, and nausea
• Hyperpigmentation from excessive melanocyte
  stimulating hormone production
• Body hair loss in females from reduced androgen
  production

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Endocrine

• Adrenal insufficiency
• Investigation
• Low baseline cortisol confirms the diagnosis
• Hyponatremia, hypoglycemia, hypercalcemia,
  eosinophilia are common but not diagnostic
• ACTH is high in primary adrenal insufficiency and
  low in secondary adrenal insufficiency
• Treatment
• If in shock, tx the shock condition
  (fluids/inotropes)
• High dose corticosteroids b/c baseline cortisol
  levels are low
• Tx any infection
• Tx hypoglycemia with glucose

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Endocrine

• Adrenocortical excess
• Cushings syndrome (steroid use) and Cushings dx
  (pituitary tumor) increase cortisol levels
• Moon face, easily bruised skin, HTN, diabetes,
  osteoporosis, central obesity, and hypokalemia
• Can also have excess aldosterone secretion with
  adrenal adenoma

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Endocrine

• Other endocrine emergencies
• Hypopituitary crisis
• Follows pituitary trauma/tumor/hemorrhage/
  infarction
• Reduced anterior pituitary hormone secretion
  causes adrenal and thyroid insufficiency and
  hypogonadism
• Decreased ADH release from posterior pituitary
  causes diabetes insipidus with thirst,
  dehydration, and severe polyuria
• Pheochromocytomas
• Rare, benign adrenal tumors that release
  catecholamines
• Often familial and there are usually other
  endocrine tumors
• Drugs, surgery, and certain foods can bring on a
  crisis
• HA, sweating, flushing, arrhythmias, HTN,
  increased plasma catecholamines
• Treat with alpha blockers, beta blockers, and
  surgery