Diabetic and Endocrine Emergencies.ppt

8/10/2019 Diabetic and Endocrine Emergencies.ppt

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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 factorscause pancreatic beta islet cell destructionleading 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 areinsulin resistant

Has genetic ties, but diet and obesity determinethe 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


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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 itbuilds up in the blood which takes water with

itin the meantime, the cells begin to metabolizefat for energy, which produces ketoacids

Clinical presentation: hyperventilation andhypotension/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 toprevent 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 andhyperosmolality

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-threateninghypermetabolic 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, N&V, heart failure, atrial fib,diarrhea, muscle rigidity/spasm


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Endocrine Thyrotoxic emergency

Specific therapy

Beta blockers: blocks effect of thyroid toreduce 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 withunrecognized hypothyroidism or patientswho 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 Twaves, 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 followingadrenal 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) increasecortisol 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 adrenaland thyroid insufficiency and hypogonadism

Decreased ADH release from posterior pituitary causes diabetesinsipidus 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 plasmacatecholamines

Treat with alpha blockers, beta blockers, and surgery

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Diabetic and Endocrine Emergencies.ppt

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