1. Dr Clutter has no financial conflicts to disclose. Or does he?

2. Endocrine Emergencies
Learning objectives: understand the diagnosis and treatment of major endocrine emergencies:
Diabetic ketoacidosis
Hyperosmolar coma
Severe hypercalcemia
Adrenal crisis
Hyperthyroidism
Hypothyroidism

3. Diabetic ketoacidosis: pathogenesis
INSULIN DEFICIENCY +
COUNTERREGULATORY HORMONES
HYPERGLYCEMIA
KETOACIDOSIS

4. Diabetic ketoacidosis: pathogenesis
HYPERGLYCEMIA
PRERENAL
AZOTEMIA
GLYCOSURIA -
OSMOTIC DIURESIS
WATER > Na
DEPLETION
K DEPLETION
HYPOTENSION

5. Diabetic ketoacidosis: pathogenesis
NAUSEA
ABDOMINAL PAIN
KETONURIA
OSMOTIC
DIURESIS
HYPERCHLOREMIC
ACIDOSIS

6. Diabetic ketoacidosis: pathogenesis
HYPERGLYCEMIA
WATER DEPLETION
HYPEROSMOLARITY
STUPOR & COMA

7. Diabetic ketoacidosis: causes
In Type 1 diabetes
new onset
inadequate insulin dose
illness:
Infection, inflammation
MI, stroke
surgery, trauma

8. Hyperosmolar Nonketotic Coma
Older, type 2 diabetics
Pre-existing renal failure
More severe volume depletion
Drugs as precipitants
Steroids
Thiazides
Phenytoin

9. Diabetic ketoacidosis: presentation
Thirst, polyuria
Nausea, vomiting, abdominal pain
Somnolence (coma in 10%)
Tachycardia, hypotension
Kussmaul respiration
Abdominal tenderness (no rebound)
Signs of triggering illness (eg fever)

10. Diabetic ketoacidosis: Rx goals
Correct volume & potassium deficits
Find & treat cause
Avoid complications
Correct acidosis & hyperglycemia

11. Diabetic ketoacidosis: management
Rapid diagnosis
IV saline & potassium
IV insulin
Monitor VS, I&O
[K], glucose, AG
Insulin & K infusions
Find cause
Watch for complications
Prevent recurrence
Pay attention!

12. Diabetic ketoacidosis: lab evaluation
Rapid diagnosis
Blood glucose by meter
Ketones (urine or blood) or
Direct b-hydroxybutyrate
Initial lab
BMP (potassium, anion gap)
CBC & routine admission labs
CXR if febrile, other signs of pneumonia
ABG if respiratory failure suspected

13. Diabetic ketoacidosis: lab evaluation
Calculate anion gap
AG = [Na] - [Cl] - [HCO3] (normal: 8-16)
If comatose, calculate plasma osmolarity
pOsm = 2[Na] + [glucose]/20 + [urea]/3
Follow:
Blood glucose by meter Q 1 hr
BMP & anion gap Q 2-4 hr
(not serum ketones, ABG)

14. Diabetic ketoacidosis: IV fluid
Normal saline >1 liter/hr until hypovolemia improved (VS, urine output), then
Half-normal saline until BG <300 mg/dl, then
D5/half-normal saline
Bladder catheter if comatose or unable to void
remove ASAP

15. Diabetic ketoacidosis: potassium
Initial [K] normal or increased
[K] rapidly falls with therapy
KCl 10 mEq/hr
follow [K] Q 2-4 hr & adjust rate
Cardiac monitor
If oliguria or severe renal failure present:
initial rate 5 mEq/hr

16. Diabetic ketoacidosis: insulin
Regular insulin 10 units IV push
Regular insulin 5-10 units/hr IV until AG normal
If no decrease in anion gap in 2 hr:
check IV
double insulin infusion rate
IV glucose to keep BG ng/dl
Insulin glargine 1-2 hr before stopping IV insulin
1/2 usual dose or units

17. Diabetic ketoacidosis: find the cause
Continuing clinical evaluation
If INFECTION suspected:
cultures
empiric antibiotics for clinical infection
fever is not due to DKA
leukocytosis is usual in DKA
If ABDOMINAL PAIN present:
treat DKA
follow abdominal exam, labs

18. Diabetic ketoacidosis: complications
Hypoglycemia
Hypokalemia
Coma
seek other causes if pOsm <330 mOsm/L
cerebral edema may occur in children
Aspiration

19. Diabetic ketoacidosis: common management errors
Too little fluid
Too little insulin
IV dose reduced
No insulin glargine
Reliance only on sliding scale insulin
Too little clinical evaluation
Too much attention to trivia (eg phosphate)

20. Severe hypercalcemia: signs
Renal:
polyuria, dehydration
renal failure
Gastrointestinal:
nausea, vomiting, constipation
abdominal pain
Neurologic:
fatigue, confusion
coma

21. Severe hypercalcemia: causes
Malignancy:
Breast carcinoma
Squamous carcinoma (lung, head & neck, esophagus)
Myeloma
Renal carcinoma
Primary hyperparathyroidism
Miscellaneous:
vitamin D intoxication
milk-alkali syndrome (calcium carbonate)
sarcoidosis

22. Severe hypercalcemia: evaluation
Evidence of cancer
Evidence of primary hyperparathyroidism
Hypercalcemia for >6 months
h/o renal stones
Plasma PTH, 25-OH vitamin D
Other labs as needed:
SPEP, UPEP
1,25-OH D
chest & abdomen CT
bone scan
(PTH-rP)

23. Severe hypercalcemia:
Principles of therapy
Expand ECF volume
Increase urinary calcium excretion
Decrease bone resorption
Indications for emergent therapy
Symptoms of hypercalcemia
Plasma [Ca] >12 mg/dl

24. Severe hypercalcemia: therapy
Restore ECF volume / saline diuresis
Normal saline rapidly
Positive fluid balance >2 liters in first 24 hr, then
Normal saline ml/hr (replace potassium)
Zoledronic acid 4 mg IV over 15 min or
Pamidronate 60 mg IV over 4 hr
Monitor plasma calcium QD
Myeloma or vitamin D toxicity:
prednisone 30 mg BID
Optional: Calcitonin 4-8 units/kg IM or SC Q12h

25. Adrenal failure: causes
Primary (cortisol & aldosterone deficient)
AUTOIMMUNE
tuberculosis, fungal infections
Bilateral hemorrhage, sepsis, etc
Secondary (ACTH & cortisol deficient)
GLUCOCORTICOID THERAPY
hypothalamic or pituitary lesions

26. Adrenal failure: signs
In both primary & secondary adrenal failure
Weakness & fatigue
Anorexia & weight loss
Nausea & vomiting
Lethargy, stupor
Hyponatremia
Hypotension
Shock & death
Only in primary adrenal failure:
Hyperkalemia
Hyperpigmentation

27. Adrenal failure: emergency evaluation
Dexamethasone 10 mg IV
Cortrosyn stimulation test:
Cortrosyn 250 mcg IV
Plasma 30 min
Normal: >18-20 mcg/dl

28. Adrenal failure: emergency therapy
Indications:
Hypotension
Stupor
Severe hyperkalemia or hyponatremia
Hydrocortisone mg IV Q 8 hr
D5/normal saline

29. Hyperthyroidism: indications for emergency management
Acute coronary syndrome
Severe heart failure
“Thyroid storm”
fever
agitation or stupor
severe concomitant illness

30. Hyperthyroidism: emergency management
Confirm hyperthyroidism (free T4, TSH)
Methimazole 60 mg QD po or per tube or
PTU 300 mg Q6 hr po
Iodine (SSKI) 2 gtt (80 mg) po Q 12 hr
Beta- adrenergic antagonist if not in CHF
propranolol 40 mg Q 6 hr
adjust dose to HR <100/min

31. Hyperthyroidism: emergency management
Intensive therapy of concomitant disease
Follow free T4 Q 4-6 days
When free T4 normal, schedule RAI therapy
stop iodine >2 weeks before
stop methimazole 3 days before

32. Hypothyroidism: emergent therapy
Indications:
Hypoventilation
Bradycardia
Hypotension
Stupor
Confirm diagnosis: FT4, TSH
T mg IV Q 6 hr x 24 hr, then
T mg IV Q 24 hr
Monitor cardiac rhythm, evidence of myocardial ischemia

33. Any questions?