Endocrine
Emergencies
Name a Few…
 DKA
 HONK
(HHOS)
 Addisonian crisis
 Thyroid storm
 Myxoedemic coma
What’s the Diagnosis?
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83yr woman with 3/7 histroy of malaise and
polyuria. PMH type I DM and HTN
HR 100, BP 100/60, GCS 14, SaO2 100% on high
flow O2
Na 125
K 6.0
Cl 81
HCO3 7
Ur 25
Cr 262
Glu 54.5
Osmolality 337
DKA
 Definition
– BSL
– Ketones
– Anion gap
– HCO3
– pH
 Mortality
increased
present
>10
<15
<7.3
5-15% (less in children)
 Beware if pregnant: 30-50% mortality
All About Ketones

Beta-hydroxybutyrate
– Detected by Medisense blood test
– Higher in alcoholic ketoacidosis than
in DKA
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Acetoacetate
– >6x the levels of above AFTER
conversion (ie. May initially be
negative)
– measured by Ketostix urine test
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Acetone
– Detected on Acetest
– Responsible for ketotic breath
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How do ketones impact on
management?
– Endpoint = ketones cleared, normal
anion gap
Other Vital Stuff
– VBG
Anion gap metabolic acidosis
– BSL
How does BSL impact on management?
Maybe metabolic alkalosis (vomiting), resp alkalosis (hyperventilation)
Aim decr no more than 5/hr
– Na…
How do I calculate corrected Na????
Na + ( (Glu – 5.5) / 3 )
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How do I correct K for pH????
Decr pH by 0.1 = Incr K by 0.5
How do I calculate osmolality?
Do I even have to? Can’t I just measure it??
(2 x Na) + Glucose + Urea
How does osmolality impact on management?
–
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Aim decr by no more than 1-2/hr
Any other investigations?
–
Average deficit 3-5mmol/kg
So if pH is 7 and K is 5.7 – what is real K?
How does K impact on management?
– Osmolality…
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So if Na is 128 and Glu is 65 – what is real Na?
How does Na impact on management?
– K…
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Average deficit 5-10mmol/kg
?precipitant; ?ARF; ?level of long-term control
Average body H20 deficit 100ml/kg
(ie. 10% dehydration)
Let’s look at that gas again…
 Na
125
 K 6.0
 Cl 81
 HCO3 7
 Ur 25
 Cr 262
 Glu 54.5
 Osmolality 337
Management of DKA
 It’s
bloody confusing and hard to
remember
 Split into…
1)
2)
3)
4)
IV fluids
Potassium
Insulin
NaHCO3
Fluids
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Adult
1L stat
Child
10-20ml/kg bolus
 rpt until haemodynamically stable
1L over 1hr
 1L over 2hrs
 1L over 4hrs
 1L over 10hrs
Replace deficit over 48hrs
Deficit = %dehydration x weight x 10
Use 0.45% saline
if Na >150 / Osm >320
Use N saline
Use 0.45% saline and correct over 72hrs
if Na >150 / Osm >320
Watch: Na, osmolality, BSL
Change to 0.45% saline + 5% dex when BSL <15
and also if…..
BSL decreasing too fast (ie. >5/hr)
BSL <10 but ketones ongoing
Potassium
How do you correct for pH again?
 Only add K in 2nd hour / once UO / K <5
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Adult
– K 4-5
– K 3-4
– K <3
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= 10mmol/hr
= 30mmol/hr
= 40mmol/hr
Child
– Add 40mmol to 1L bag
Insulin
Start after 1hr of fluids
if K >3.4 (otherwise
replace K first)
 Do you give a stat dose of actrapid?
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Actrapid infusion
– 0.1iu/kg/hr (max 6iu/hr)
– Decrease to 0.05iu/kg hr if….
 BSL
<12 (stop for 15mins if still too low despite this)
 Aim for BSL decrease of no more than 5/hr
 K <3
NaHCO3
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What are the indications?
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pH <7
HCO3 <5
Life threatening hyperkalaemia
Coma
Haemodynamic compromise
unresponsive to IV fluids
What is the dose?
– 0.5 – 2mmol/kg over 1-2hrs
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What is the endpoint?
– pH >7.1
– HCO3 >10
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What are the risks?
– Worsened intracellular acidosis, hypokalaemia, hypernatraemia,
osmolar shifts and cerebral oedema, volume overload
Cerebral oedema
 70%
mortality; 10% have ongoing
neuro deficit; more common in
children
 Onset 4-12hrs after starting trt
 What are the symptoms?
– Headache, decr LOC, decr HR, incr BP,
pupil changes, seizure, urinary
incontinence
 How
do you treat it?
– Mannitol 0.5-1g/kg
– 3% saline 5-10ml/kg over 30mins
– Half maintenance fluids
Hyperglycaemic Hyperosmolar State
DKA
HHOS
Mortality up to 15%
Mortality up to 45%
BSL +
BSL ++++
pH <7.3
pH >7.3
Anion gap >12
Anion gap <12
HCO3 <15
HCO3 >15
Ketones ++++
Ketones -/+
Maybe incr osmolality
Osmolality >320-350
H20 deficit 100ml/kg (10% dehydration)
H20 deficit more (20-25% dehydration)
Higher Na + K deficit
Resus with N saline
Use N saline thereafter unless Na >150 / Osm
>320
Use 0.45% saline thereafter (unless low
corrected Na)
Change to 0.45% saline + 5% dex when BSL <15
Replace deficit over 48hrs
Replace deficit over 48-72hrs
Similar K replacement
Actrapid 0.1iu/kg/hr (max 6iu/hr)
Actrapid
0.05iu/kg/hr (max 3iu/hr)
Heparin important (hypercoag state)
What’s the diagnosis (bearing in
mind this is an endocrine talk)?
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An 85 year old man is brought to your Emergency Department fitting. His
family say that he has been lethargic and weak for the last two weeks. He
has a PMH of polymyalgia rheumatica. These are his initial biochemistry
results.
Na 99 mmol/L
K 5.9 mmol/L
Cl 68 mmol/L
BSL 2.2mmol/L
HCO3 - 21 mmol/L
Urea 10.1 mmol/L
Cr 180 umol/L
pH 7.1
Anion gap normal
pCO2 31 mmHg
pO2 149.5 mmHg
BE 2.4
HCO3 17.6 mmol/L
Addisonian Crisis
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Back to Part One’s!!
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Effects of cortisol
– Incr BSL (gluconeogenesis, lipolysis, decr ketogenesis, decr insulin release)
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Effects of aldosterone
– Incr Na (incr reabsorption)
– Decr K (incr excretion in DCT)
– Alkalosis (incr H excretion)
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So…. what changes may be seen on bloods in view of the above?
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Dehydration – fluid resistant hypotension
Decr osmolality
Decr BSL
Decr Na, Cl
Incr K
Non-anion gap metabolic acidosis
– If 2Y hypoadrenalism patient euvolaemic with lower K, as aldosterone is still
working
Recognising Addisonian Crisis
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Who gets it?
– 1Y
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– 2Y
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Long-term steroids stopped abruptly
Adrenal haemorrhage (neonates, anticoagulated folk, sepsis (name the
syndrome), trauma)
Addison’s disease
Prior surgical removal
Adrenal destruction due to other cause: infection (eg. TB, HIV, CMV),
thrombosis, metastatic Ca
Head trauma
Meningitis
In pregnancy (name the syndrome).
Pituiary failure
How do they present?
– Hypotension, lethargy, weight loss,
weakness, N+V, abdo pain, diarrhoea
– Ie. Non-specifically unwell and not responding
to conventional treatment plus characteristic
electrolyte changes
Management
 Investigation
– Name the investigation
 Management
– IV fluids ++++ (vasopressors may be
needed)
– Dextrose
– Treat K if needed
– Dexamethasone 10mg IV stat (give
initially as doesn’t interfere with
investigations)
– …then hydrocortisone 250mg IV stat
What’s the diagnosis?
17yr old female presents feeling anxious,
unwell, tremulous, hyperventilating,
looking flushed. Recent history of
abdominal pain and diarrhoea.
 HR 130, T 38, BP 140/87, RR 24
 On examination: gallop rhythm, bibasal
crepitations, abdomen SNT
 pH
7.8
 PCO2
15 mmHg
 PO2
192 mmHg
(75-100)
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Thyroid Calamities
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Back to Part
One’s again!
Effect of T3+4
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Incr metabolism
Incr GI motility
Incr glucose absorption
Incr sensitivity to epinephrine and
norepinephrine, increased beta-receptors
Thyroid Storm
Clinical diagnosis – labs don’t differentiate
 Mortality 10% treated, 90% untreated
with death due to CV collapse
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Who gets it?
– Undiagnosed Graves
– Meds – XS thyroxine / withdrawal from antithyroid drugs / iodine or contrast
– Stressor – MI, DKA, OT
Recognising Thyroid Storm
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Diagnostic criteria
– Fever >37.8
– Incr HR out of proportion to fever (ie. >120)
– CNS disturbance (eg. Altered LOC, seizures)
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Other
– AP, N+V, diarrhoea, high output CCF (wide
pulse pressure, S3 gallop rhythm), HTN,
dehydration, sweating
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Investigations – non-specific
Management
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A+B
– Give O2 as consumption increased
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C
– IV fluids containing dextrose
– Cardioversion better than drugs for arrhythmias
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Treat cause
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Definitive treatment
– Esmolol 250-500mcg/kg bolus  infusion (safe as short half life;
titratable; blocks cardiac and peripheral effects and slows conversion
of T3 to T4)
– If less severe can use PO propanolol
– Hydrocortisone 100mg IV (slows conversion of T3 to T4 and decreases
hormone release)
– Propylthiouracil / methimazole / iodide
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Supportive care
– Ongoing fluids, monitor electrolytes and BSL, treat fever
What’s the Diagnosis? (This was
an actual patient I saw last week)
 58yr
old man with non-specific
malaise
 PMH: hyperthyroidism treated with
radioactive iodine; known to be noncompliant with treatment
 OE: normal observations; mild
oedema around eyes; examination
otherwise unremarkable
Myxoedema Coma
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Who’s ever seen one???
Mortality 50%; same triggers as thryoid storm
Symptoms
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A: hoarseness, glottic oedema
B: decr RR
C: decr BP, CCF
D: decr LOC, hypothermia without shivering, seizures
E: hypoglycaemia, paralytic ileus
Management
– ABC, treat cause
– T3 has rapid effect, T4 has smoother improvement, give
hydrocortisone
– Monitor electrolytes esp Na and titrate fluids accordingly
– Rewarming
Anything else you want to talk
about…?
 Hyponatraemia?
 Hypernatraemia?
 Metabolic
acidosis?
 Sodium bicarb use?