Endocrine Emergencies
Endocrine Disorders
and Emergencies
 Endocrine System
 Physiology/Patho
 Function
 Disorders of the Pancreas
 Disorders of the Thyroid Gland
 Disorders of the Adrenal Glands
Endocrine System
 Consists of glands that secrete
hormones
 Maintains homeostasis with the use of
hormonal chemical messengers…tend
to be widespread in effect
Hormones
 Are released as changes in the
internal environment occur
 Transported by the blood throughout
the body
 One may control the secretion of
another
 Hormonal action controlled by
negative feedback
The Endocrine System
There are eight major glands in the endocrine system:
Hypothalamus
Pituitary
Thyroid
Parathyroid
Thymus
Pancreas
Adrenals
Gonads
Pineal
They are located throughout the body.
The Major Glands of the
Endocrine System
Disorders of the Pancreas
 Beta Cells secrete insulin to
decrease blood sugar
 Alpha Cells secrete glucagon to
increase blood sugar
 Delta cells secrete somatostatin
suppresses secretion of glucagon
and insulin
Disorders of the Pancreas
 Glucose Metabolism
 anabolism & catabolism
Disorders of the Pancreas
Insulin is required for glucose metabolism
 Presence of enough insulin to meet cellular needs.
 Ability to bind in a manner to stimulate the cells
adequately.
 When unable to obtain energy from glucose, the
body begins to use fatty stores.
• Ketones and ketosis.
 Regulation of Blood Glucose
 Hypoglycemia and hyperglycemia
 Role of pancreas, liver, and kidneys
 Osmotic diuresis and glycosuria
Insulin
Regulated by glucose in the
body
 After a meal
>>>hyperglycemia
 pancreas stimulates
insulin via the islet cells
[beta cells]
 Secretion is halted when
the blood glucose is low
>>>hypoglycemia
[Negative Feedback]
Glucagon
 Insulin antagonist
– actions are
opposite
 Secreted during
low levels of
glucose
>>>hypoglycemia
 Causes glucose to
move from cells,
specifically the
liver
Regulation of Insulin Secretion
Glut-2
Liver
Releases
glucose
and
ketones
GLUCOSE
glucagon
insulin
somatostatin
Endocrine Pancreas
Increased
secretion
of Insulin
Decreases
blood glucose
Pathogenesis of
Diabetes
Impaired Transport of Glucose
into Cells
CELL ENERGY
HYPERGLYCEMIA
breakdown of
fat and protein
blood osmolality
cells shrink
glycosuria
ketogenesis
dehydration
Fruity Kussmaul Coma
breath resp
thirst
HR
warm,dry
Diabetes Mellitus
 Type I Diabetes Mellitus
 Also called juvenile or insulin-dependent diabetes
mellitus (IDDM).
 Characterized by low production of insulin.
 Closely related to heredity.
 Results in pronounced hyperglycemia.
 Symptoms of untreated Type I DM include
polydipsia, polyuria, polyphagia, weight loss,
and weakness.
 Untreated or noncompliant patients may
progress to ketosis and diabetic ketoacidosis.
Diabetes Mellitus
 Type II Diabetes Mellitus
 Also called adult-onset or non-insulin-dependent
diabetes mellitus (NIDDM).
 Results from decreased binding of insulin to cells.
 Related to heredity and obesity.
 Accounts for 90% of all diagnosed diabetes
patients.
 Less risk of fat-based metabolism.
 Results in less-pronounced hyperglycemia.
 Hyperglycemic hyperosmolar nonketotic
acidosis.
 Managed with dietary changes and oral drugs
to stimulate insulin production and increase
receptor effectiveness.
Diabetic Emergencies
Diabetic Emergencies
Diabetic Emergencies
 Diabetic Ketoacidosis - Hyperglycemia
Pathophysiology
 Results from the body’s change to fat metabolism.
 Continuous buildup of ketones produces significant
acidosis.
Signs and Symptoms
 Extended period of onset (12–24 hours).
 Sweet, fruity breath odor.
 Potassium-related cardiac dysrhythmias.
 Kussmaul’s respiration.
 Decline in mental status and coma.
Diabetic Emergencies
Assessment and Management
 Focused History & Physical Exam
• Obtain SAMPLE and OPQRST histories.
• Look for medical identification.
 Management
• Maintain airway and support breathing as indicated.
• Determine blood glucose level and obtain blood
sample.
• If blood glucose unknown, administer 25g 50%
dextrose.
• Establish IV and administer normal saline per local
protocol.
• Monitor cardiac rhythm and vital signs.
• Expedite transport.
The future
1 - Continuous glucose sensor monitors blood sugar level
2 - Data transmitted for the computer program to work out insulin dose
3 - Insulin pump delivers the dose
Diabetic Emergencies
 Hyperglycemic Hyperosmolar
Nonketotic (HHNK) Coma
Pathophysiology
 Found in Type II diabetics.
 Results in blood glucose levels far above the
norm
 Insulin activity prevents buildup of ketones.
 Sustained hyperglycemia results in marked
dehydration.
• Often related to dialysis, infection, and
medications.
 Very high mortality rate.
Hyperglycemic Hyperosmolar
Nonketotic (HHNK) Coma
 Signs & Symptoms
 Gradual onset over days.
 Increased urination and thirst, orthostatic
hypotension, and altered mental status.
 Assessment & Management
 Difficult to distinguish from diabetic
ketoacidosis in the prehospital setting.
 Treatment is identical to diabetic
ketoacidosis.
Diabetic Emergencies
 Hypoglycemia
Pathophysiology
 True medical emergency resulting from low
blood glucose levels; rarely seen outside
diabetics.
 By the time signs and symptoms develop, most
of the body’s stores have been used.
 Diabetics with kidney failure are predisposed
to hypoglycemia.
Hypoglycemia
 Signs & Symptoms
 Altered mental status with rapid onset
 Frequently involves combativeness.
 Diaphoresis and tachycardia
 Hypoglycemic seizure and coma
 Assessment and Management
 Focused History & Physical Exam
 Obtain SAMPLE and OPQRST
histories.
 Look for medical identification.
Management
Diabetic Emergencies
• Maintain airway and support breathing as
indicated.
• Determine blood glucose level and obtain blood
sample.
• Establish IV access.
• If blood glucose <4.0 mmol/L or is unknown,
administer 50 ml of 50% Dextrose IV.
• If IV cannot be established, administer 0.5–1.0mg
glucagon intramuscularly.
• Monitor cardiac rhythm and vital signs.
• Expedite transport.
The Canadian Diabetes Association 2003 Clinical Practice Guidelines recently lowered
the blood glucose (sugar) target levels. Canadians with type 2 diabetes need to
understand what those new levels are, and how meeting these new targets can
help them stay healthy and live well with diabetes.
Recommended Targets for People With Diabetes*
AIC
Target for most patients with
diabetes
Normal range
A1C Fasting
blood glucose /
blood glucose
before meals
(mmol/L)
Blood glucose
two hours
after eating
(mmol/L)
Blood
Pressure
Cholesterol
130 / 80
LDL: below 2.5
Total Cholesterol to HDL ratio:
below 4
=7.0
%
4.0 to 7.0
5.0 to 10.0
=6.0%
4.0 to 6.0
5.0 to 8.0
Compare Type 1 and Type 2
Type 1
Type 2
Onset
any age
adults
Weight
underweight
obese
Immune-mediated
YES
NO
Ketoacidosis
YES
NO
Insulin secretion
NO
YES
Beta cell function
NO
YES
Genetic predisposition Moderate Very
Strong
KNOW THE DIFFERENCE
HIGH
Blood Sugar
Increased thirst
and urination
hunger
ketones in urine
aching, weak
heavy breathing
nausea,vomiting
Fatigue
seizure
cold sweats
headache
trembling
pounding heart
sleepiness
personality
change
hunger
LOW
Blood Sugar
Diabetes
Now that you mastered
Diabetes Mellitus
There is More!!!!!
What is Diabetes Insipidus?
Disorders of the
Thyroid Gland
 Grave’s Disease
Pathophysiology
 Probably hereditary in nature.
 Autoantibodies are generated that stimulate
thyroid tissue to produce excessive hormone.
Signs & Symptoms
 Agitation, emotional changeability, insomnia,
poor heat tolerance, weight loss, weakness,
dyspnea.
 Tachycardia and new-onset atrial fibrillation.
 Protrusion of the eyeballs or goiters.
Disorders of the
Thyroid Gland
Assessment & Management
 Usually arise from cardiovascular
signs/symptoms.
• Manage signs and symptoms.
 Thyrotoxic Crisis (Thyroid Storm)
Pathophysiology
 Life-threatening emergency, usually associated
with severe physiologic stress or overdose of
thyroid hormone.
 Results when thyroid hormone moves from
bound state to free state within the blood.
Disorders of the
Thyroid Gland
Signs & Symptoms
 High fever (106º F or higher)
 Reflected in increased activity of sympathetic
nervous system.
• Irritability, delirium or coma
• Tachycardia and hypotension
• Vomiting and diarrhea
Assessment and Management
 Support airway, breathing, and circulation.
 Monitor closely and expedite transport.
Disorders of the
Thyroid Gland
 Hypothyroidism and Myxedema
Pathophysiology
 Can be inherited or acquired.
 Chronic untreated hypothyroidism creates
myxedema.
• Thickening of connective tissue in skin and
other tissues.
• Infection, trauma, CNS depressents, or a cold
environment can trigger progression to a
myxedemic coma.
Disorders of the Thyroid Gland
 Signs &
Symptoms
 Fatigue, slowed
mental function
 Cold
intolerance,
constipation,
lethargy
 Absence of
emotion,
thinning hair,
enlarged tongue
 Cool, pale
doughlike skin
 Coma,
hypothermia,
and bradycardia
Disorders of the
Thyroid Gland
 Assessment and Management




Focus on maintaining ABCs.
Closely monitor cardiac and pulmonary status.
Establish IV access, but limit fluids.
Expedite transport.
Disorders of the Thyroid Gland
 Signs &
Symptoms
 Weight gain
 “Moon-faced”
appearance
 Fat
accumulation on
the upper back
 Skin changes
and delayed
healing of
wounds
 Mood swings
 Impaired
memory or
concentration
Disorders of the
Adrenal Gland
 Hyperadrenalism
(Cushing’s Syndrome)
 Pathophysiology
 Often due to abnormalities in the anterior pituitary or
adrenal cortex.
 May also be due to steroid therapy for nonendocrine
conditions such as COPD or asthma.
 Long-term cortisol elevation causes many changes.
• Atherosclerosis, diabetes, hypertension
• Increased response to catecholamines
• Hypokalemia and susceptibility to infection
Disorders of the
Adrenal Gland
Assessment & Management
 Support ABCs.
 Use caution when establishing IV access.
 Report any observations indicative of Cushing’s
Syndrome to the receiving facility.
 Adrenal Insufficiency (Addison’s Disease)
 Pathophysiology
 Due to destruction of the adrenal cortex.
 Often related to heredity.
 Stress may trigger Addisonian crisis.
Disorders of the
Adrenal Gland
 May be related to steroid therapy.
• Sudden withdrawal can trigger Addisonian
crisis.
Signs & Symptoms
 Progressive weakness, fatigue, decreased
appetite, and weight loss
 Hyperpigmentation of skin and mucous
membranes
 Vomiting or diarrhea
 Hypokalemia and other electrolyte
disturbances
 Unexplained cardiovascular collapse
Disorders of the
Adrenal Gland
Assessment and Management
 Maintain ABCs.
 Closely monitor cardiac and pulmonary status.
 Obtain blood glucose level and treat for
hypoglycemia if present.
 Establish IV and provide aggressive fluid
resuscitation.
 Expedite transport.
Summary
 Endocrine Disorders and
Emergencies