Endocrine Emergencies

1. Endocrine Emergencies David C. Seaberg, MD, FACEP Department of Emergency Medicine

2. Endocrine Emergencies • Hypoglycemia • DKA • Hyperosmolar Non-ketotic Coma (HONK) • Lactic Acidosis • Hypothyroidism • Hyperthyroidism • Pheochromocytoma • Addison’s Disease

3. Glucose Metabolism • Food intake • Glucose stimulates insulin • Insulin converts glucose into glycogen • Insulin also: • inhibits gluconeogenesis • enhances lipogenesis, restrains lipolysis • enhances uptake of amino acids into muscle

4. Endogenous Fed early DM idiopathic Fasting Islet-cell tumor Endocrine deficiency Hepatic disease Starvation Chronic renal failure Exogenous Insulin Factitious Alcohol Drugs HypoglycemiaCauses

5. Hypoglycemia Factitious vs. Islet-cell tumor • Proinsulin breaks down into insulin and C-peptide, in equal amounts • Factitious will have insulin antibodies

6. Hyperglycemia • Diabetic ketoacidosis • Hyper osmolar non-ketotic coma (HONK)

7. Hyperglycemia

8. Hyperglycemia • Insulin lack • Symptoms: • polyuria, polydipsia, N/V • Kussmaul breathing, dry skin, acetone breath • Glycolysis, lipolysis • 3 ketones • acetone, acetoacetate, -hydroxybutyrate

9. DKA • Causes: • infection most common • silent MI, CVA, decreased insulin intake, drugs, pregnancy, pancreatitis • Average fluid deficit = 6-8 liters

10. DKA • Labs: •  glucose •  bicarb,  potassium,  pH • Increased anion gap • AG = [Na - (Cl + HCO3)] = 12 + 4mEq/L

11. Anion Gap Metabolic Acidosis Aspirin/AKA Methanol Uremia DKA Paraldeyde INH/Iron Lactic acidosis Ethylene glycol

12. DKA Treatment • Fluid • Insulin • Avoid high-dose insulin • delayed hypoglycemia • delayed hypokalemia • ? Bicarbonate • Watch Potassium • Watch Phosphate

13. Nonketotic Hyperosmolar Coma • Like DKA: hyperglycemia, hyperosmolar • Lacks ketoacidosis • Blood glucose > 800 • Serum osmolality > 350 • negative serum ketones • 2/3 of pts have no h/o diabetes • Average fluid deficit: 9 liters

14. Nonketotic Hyperosmolar Coma

15. Nonketotic Hyperosmolar Coma • Serum osmolality: 2 [Na] + glucose/18 + BUN/2.8 • 50% may have metabolic acidosis due to: lactate, ß-hydroxybutyrate, renal insufficiency

16. Thiazide diuretics lasix diazoxide Ca channel blockers glucocorticoids dilantin thorazine Tagamet inderal mannitol peritoneal dialysis hemodialysis Drugs and Procedures that cause Nonketotic Hyperosmolar Coma

17. Diffuse Seizures Lethargy Confusion Delerium/hallucinations Stupor Coma Focal Focal seizures Todd’s paralysis hemiparesis aphasia hemianpsia nystagmus hyperrelexia choreoathetosis Neurological Manifestations of Nonketotic Hyperosmolar Coma

18. Nonketotic Hyperosmolar Coma Treatment • Saline: isotonic vs. hypotonic • 2 liters in first 2 hours • may need CVP or PCWP to monitor • Insulin • Glucose - add when serum glucose < 250 • Phosphorus • Watch Potassium

19. Alcoholic Ketoacidosis • Mechanism unknown • Ketosis form increased mobilization of FFA • Increased liver metabolism • Increased anion gap with high levels of ketoacids

20. Alcoholic Ketoacidosis • Symptoms: • alcohol intake, decreased food intake • Abdominal pain • dehydration • N/V • Lab: • WAGMA • Glucose < 300, sometimes normal or low

21. Alcoholic Ketoacidosis • Lab: • Ethanol level = 0 • measured serum ketones may be normal • Nitroprusside reaction only measures acetone and acetoacetate • ß-hydroxybutyrate is main ketone formed in AKA

22. Alcoholic Ketoacidosis • Treatment • Saline • Glucose • Thiamine

23. Lactic Acidosis • Most common metabolic acidosis • Type A • tissue anoxia • hypotension, hypoxia • Type B • Disorders: DM, RF, Infection, Liver dz, malignancy • Drugs/Toxins: biguanides, methanol, • Hereditary: glycogen storage dz

24. Lactic Acidosis Treatment Restore circulation Bicarbonate?

25. Thyroid Storm • Most often seen with moderate to severe antecedent Graves Disease • Precipitating factors: • infection, DKA, • Symptoms: • tachycardia out of proportion to fever • GI symptoms: anorexia, N/V, abdominal pain • CNS disturbances • Cardiovascular: arrythmias, A-fib, PVC’s, CHF

26. Hyperthyroidism

27. Thyroid Storm • Lab • no lab tests confirm throid storm • elevated T3 and T4 • Increased RAI uptake

28. Apathetic Thyrotoxicosis • Elderly patients • thryoid storm without hyperkinetic manifestations • Sx: • lethargy, slowed mentation, apathetic facies, goiter • absence of exophthalmos but may have drooping of upper eyelid • wt loss and muscle weakness • A-fib

29. Thyroid Storm: Treatment • General supportive care • saline, avoid aspirin • Inhibit thyroid hormone synthesis • PTU, 900 - 1200 mg • Retard thyroid hormone release • KI, 1g q8-12 hr • Block peripheral effects • ß-blockers • glucocorticoids

30. previous thyroid operation goiter present hypothermia coarse voice sella turcica normal cardiomegaly normal menses dry skin no response to TSH good response to levothyroxine increased TSH Myxedema ComaPrimary Hypothyoidism (Thyroid):

31. No previous thyroid operation no goiter present less hypothermia coarse less voice sella turcica increased plasma cortisol level decreased small heart size abnormal menses skin fine and soft good response to TSH poor response to levothyroxine decreased TSH Myxedema ComaSecondary Hypothyoidism (Pituitary):

32. Myxedema Coma • precipitating cause • 80% are hypothermic • respiratory failure • hyponatremia • cardiomegaly • pericardial effusion • coma • megacolon

33. Myxedema

34. Myxedema Coma Treatment: • Supportive • rewarm • ventilatory support • treat precipitating cause • hydrocortisone, 300mg/d • Thyroid hormone • thyroxine, 400-500 ug, iv

35. Adrenal Crisis • Adrenal Hormones: • Cortisol - major glucocorticoid • Aldosterone - mineralocorticoid • Androgens

36. Primary Adrenal Insufficiency • Primary, chronic • idiopathic • infiltrative or infectious (TB, sarcoid, hemochromatosis) • hemorrhagic • drugs • Primary, acute • Hemorrhage - septicemia, newborn • discontinue steroid replacement

37. Secondary Adrenal Insufficiency • Secondary, chronic • pituitary tumor • infiltrative or granulomatous (sarcoid, hemochromatosis) • pituitary hemorrhagic • internal carotid aneurysm • head trauma • infection (meningitis, sinus thrombosis) • Secondary, acute • discontinue steroid replacement

38. Primary vs. Secondary • In secondary, pituitary is unable to secrete ACTH however aldosterone is unaffected • Secondary has insufficiency of cortisol and adrenal androgens • Secondary may have failure of other pituitary hormones

39. Addison’s Disease Primary Adrenal Insufficinecy • 90% of adrenal cortex must be involved • Sx: • anorexia, N/V, lethargy, , weakness • wt loss, abdominal pain, diarrhea • postural hypotension, syncope • may have altered mental status • pigmentation (lack of ACTH)

40. Addison’s Disease

41. Addison’s Disease

42. Addison’s Disease Primary Adrenal Insufficinecy • Lab • hyponatremia • hyperkalemia • hypoglycemia • azotemia • EKG • flat/inverted T waves, low voltage, prolonged QT, hyperkalemia changes

43. Addison’s Disease Primary Adrenal Insufficinecy • Diagnosis • low baseline cortisol levels • poor response to ACTH • ACTH (corticotropin) stim test - max response at 1 hr

44. Addison’s Disease Primary Adrenal Insufficinecy • Treatment 1. Supportive • saline, glucose 2. Hormone replacement • Glucocorticoid: 20 - 37.5 mg/day • Mineralocorticoid • Florinef, 0.05 - 0.2mg/day • Androgen • fluoxymesterone, 2-5 mg/day

45. Pheochromocytoma • Tumor of adrenal medulla • Release epinephrine and norepinephrine • Acute hypertensive crisis - 90% • Often precipitating factors: • exercise, anethetics, MAOI, surgery, tyramine • Other sx: sweating, heat intolerance, wt loss, hyperglycemia, orthostasis

46. Pheochromocytoma

47. Pheochromocytoma • Treatment - antihypertensives • Alpha-blockers: • phentolamine: 2 - 5 mg q5 min • phenoxybenzamine • Nitroprusside • Labetalol • Avoid beta-blockers initially • Surgery