ENDOCRINE EMERGENCIESPart 2Presented by: Stacy Arvinna Binti JamarunDepartment : Emergency.

1. Hypoglycaemia2. Diabetic Ketoacidosis3. Hyperosmolar

Hyperglycaemic State

Pituitary apoplexy

1. Addisonian Crisis2. Phaeochromocyto

ma hypertensive crisis

1. Thyroid storm2. Myxoedema coma Parathyroid

glandHypo / hypercalcaemia

PHAEOCHROMOCYTOMA / CATECHOLAMINE CRISISPhaeochromocytomas are catecholamine

secreting tumours of the adrenal medulla< 0.1% Hypertension, but may cause

hypertensive emergencies (SBP > 220mmHg or DBP > 120 mmHg)

10% bilateral10% extra-adrenal10% malignant10% familial (Neurofibromatosis, Von Hippel

Lindau, MEN 2, SDHD/SDHB mutations)

PHAEOCHROMOCYTOMA / CATECHOLAMINE CRISISSecretory Products: - Noradrenaline / normetanephrines - Adrenaline / metanephrines - Dopamine

PHAEOCHROMOCYTOMA / CATECHOLAMINE CRISISClinical Features :

- Hypertension - Anxiety attacks - Sweating and heat intolerance - Flushing / Pallor, palpitations, pounding

headaches, pyrexia - Tachycardia / arrhythmias

PHAEOCHROMOCYTOMA / CATECHOLAMINE CRISISCrisis Precipitants : - Straining - Exercise - Pressure on abdomen - Surgery - Drugs

PHAEOCHROMOCYTOMA / CATECHOLAMINE CRISIS(4)Laboratory Findings : - Hyperglycaemia - Hypokalaemia

Investigations : - Urinary catecholamines - Chromogranin A, B - MRI / MIBG

PHAEOCHROMOCYTOMA / CATECHOLAMINE CRISIS(5)Management : - Rehydration - Alpha blockade (Phentolamine /

phenoxybenzamine)

- LATER, Beta blockade

- Surgical resection - Screening for associated conditions

PITUITARY APOPLEXY

Apoplexy refers to infarction of the pituitary gland due either to haemorrhage or ischaemia

Causes : - Spontaneous haemorrhage - Anticoagulant therapy - Head trauma - Radiation therapy - Drugs (Bromocriptine) - Pituitary function testing

PITUITARY APOPLEXY(1)

Rare0.6 – 25% cases of treated pituitary adenoma

Clinical Features : - Headaches - Nausea, vomiting - Visual disturbance - Cranial nerve palsy - Meningism

PITUITARY APOPLEXY(2)

Diagnosis :- High degree of suspicion

- Brain imaging - Hypo / hypernatraemia may occur - Baseline pituitary function tests - Visual fields

PITUITARY APOPLEXY(3)

Management : - Stabilise the patients (A, B, C) - Hydrocortisone - Fluid balance - Early neurosurgical intervention particularly

if significant visual involvement

- Reassess pituitary function once acute apoplexy resolved

HYPOCALCAEMIA

Usually the result of failure of PTH secretion or inability to release calcium from bone

Causes : - Hypoparathyroidism (autoimmune, surgical,

radiation, infiltration) - Failure of parathyroid development - Failure of PTH secretion (Magnesium

deficiency) - Failure of parathyroid action

(Pseudohypoparathyroidism)

HYPOCALCAEMIA(1)

Causes : (contd.) - Failure of 1,25 (OH)2D levels (drugs,

pancreatitis) - Failure of calcium release from bone

(osteomalacia, renal failure, hungry bone syndrome)

- Complexing of calcium from the circulation (multiple blood transfusion, pancreatitis)

HYPOCALCAEMIA(2)

Clinical Features : - Tingling and numbness espec. of fingers,

toes or lips - Cramps - Carpopedal spasm - Tetanic contractions (may include

laryngospasm) - Seizures - Hypotension, bradycardia, arrhythmias, CCF

HYPOCALCAEMIA(3)

Investigations : - Plasma calcium, albumin and phosphate - Magnesium - U and E’s - PTH - ECG - 25 (OH) Vit D

HYPOCALCAEMIA(4)

Management : - Patients with tetany or seizures require

urgent intravenous treatment with calcium gluconate followed by an infusion for maintenance

- Chronic hypocalcaemia is best managed with oral calcium and vitamin D

HYPERCALCAEMIA

Found in 5% hospital patients but only 0.5% general population

Frequently picked up by routine biochemical screen in an asymptomatic patient

HYPERCALCAEMIA(1)

Causes : - Hyperparathyroidism - Malignancy - Hyperthyroidism - Sarcoidosis - Drug related (thiazides, vitamin D, lithium) - Immobilisation - Miscellaneous (Benign Familial

Hypocalciuric Hypercalcaemia)

HYPERCALCAEMIA(2)

Clinical Features : - Polyuria, polydipsia, dehydration - Tiredness, weakness, anorexia, malaise,

nausea - Abdominal pain, constipation - Confusion, lethargy, depression - Renal calculi, renal failure - Sudden cardiac arrest

HYPERCALCAEMIA(3)

Investigations : - Plasma Calcium (corrected for albumin) - Phosphate, Magnesium - U and E’s - LFT’s - PTH - 24 hr urine Calcium - ECG

HYPERCALCAEMIA(4)

Additional Investigations : - Myeloma screen

- TFT’s - Short synacthen test - Renal US - DEXA

HYPERCALCAEMIA(5)

Management : - Rehydration (Saline) - ± Loop diuretic - IV Bisphosphonate - Salmon calcitonin - Steroids