endocrine emergency
DESCRIPTION
Endocrine Emergency. Chatlert Pongchaiyakul MD. - Hypoglycemia - Diabetic ketoacidosis - Hyperosmolar non - ketotic coma - Focal hyperglycemic seizure. - Thyroid Crisis - Myxedema Coma - Adrenal crisis - Hypercalcemia - Acute hypocalcemia. Hypoglycemia. - PowerPoint PPT PresentationTRANSCRIPT
Endocrine Emergency
Chatlert Pongchaiyakul MD.
- Hypoglycemia
- Diabetic ketoacidosis
- Hyperosmolar non - ketotic coma
- Focal hyperglycemic seizure
- Thyroid Crisis
- Myxedema Coma
- Adrenal crisis
- Hypercalcemia
- Acute hypocalcemia
Hypoglycemia
ระดั�บ Plasma glucose ต่ำ��กว่� 50 mg/dl
“Whipple’s triad”
- low plasma glucose
- Neuroglycopenia
- Corrected by glucose
Classification
Fasting hypoglycemia
- underproduction
- overutilization
Post prandial hypoglycemia
Underproduction of glucose
Hormone deficiency
Enzyme defect
Substrate deficiency
Acquired liver disease
Drug : alcohol, propanolol,
salicylate,quinine etc.
Overutilization of glucose
Hyperinsulinism
– Insulinoma
– Exogenous insulin
– Sulfonylurea
Appropriate insulin
– Extrapancreatic tumor
– Carnitine deficiency
Treatment
• Oral intake
• Correct cause of hypoglycemia
• Monitor plasma glucose
Good conscious
Unconscious
50% glucose 50 ml IV. ต่ำมดั�ว่ย
10% Dextrose intravenous drip
125 - 250 ml/hr.
Glucagon 1 mg IM
Diabetic Emergency
DKA
HONC
Focal hyperglycemia
seizure
DKA
• Kussmaul’s breathing
• Polyuria, polydipsia, polyphagia
• Alteration of conscious
• Other : dehydration, nausea, abdominal
pain etc.
Diagnosis
Plasma glucose > 300-350 mg/dl
Wide anion gap acidosis
Serum Ketone + ve
not necessary
เกณฑ์�กรว่�นิ�จฉั�ยภว่ะDKA และHHNSDKA
Mild Moderate Severe HHNSPlasma glucose (mg/dl) >250 >250 >250 >600Arterial pH 7.25-7.30 7.00-7.24 <7.00 >7.30Serum bicarbonate (mEq/l) 15-18 10-15 <10 >15Urine ketones* Positive Positive Positive SmallSerum ketones* Positive Positive Positive SmallEffective serum osmolality (mOsm/kg)
Variable Variable Variable >320
Anion gap± >10 >12 >12 <12Alteration in sensorium or mental obtundation
Alert Atert/drowsy Stupor/coma Stupor/coma
*Nitroprusside reaction method; calculation: 2[measured Na (mEq/l)] + glucose (mg/dl)/18;±calculation (Na+) – (HCO3
- + CI- ) (mEq/I).
ที่��มา : ดั�ดัแปลงจากAmerican Diabetic Association 2001:S84.
HONC
Neurological Sign & Symptoms
Severe Dehydration
Evidence of infection
Diagnosis
- Plasma glucose > 600 mg/dl
- Effective Osmolarity > 320 mOsm/lit
- Serum Osmolarity > 340 mOsm/lit
- PH > 7.30
- HCO3 > 15 mEq/lit
- Prerenal azotemia
Treatment
Initial lab
CBC, UA, BS, BUN, Cr,
Electrolyte, ketone, ABG.
Calculated osmolarity
Septic work up
0.9% Na Cl 1000 - 1500 CC. ในิชั่��ว่โมงแรก 1000 CC. ในิชั่��ว่โมงที่ � 2 500 CC. ในิชั่��ว่โมงที่ � 3
250 CC. ในิชั่��ว่โมงที่ � 4 และต่ำ�อไป- ถ้� Na > 150 0.45% Na Cl
- ผู้&�ป'ว่ยสู&งอย) CVP
Fluid
Insulin
Short actig (IV / IM) - 10 u IV.
- 10 u IV drip / hr. ( ผู้สูมในิ Na Cl)
Monitor BS q 1 hr.
Electrolyte q 2-4 hr,
osmolarity, Anion gap
BS < 300 เปล �ยนิ 5% DW หร+อ5% DN/2 125-250 ml/hr.
Insulin 10-12 u Sc. q 4 hr.
หร+อ IV.drip low dose (2 u/hr)
NaHCO3 - pH < 6.9, 7.0
- Cardiovascular instability
: 100 mEq IV drip in 1 hr.
Potassium
If serum K 3 mEq ให� KCl 30 mEq/hr.
serum K 3-4 mEq ให� KCl 20 mEq/hr.
serum K 4-5 mEq ให� KCl 15 mEq/hr.
serum K 5-6 mEq ให� KCl 10 mEq/hr.
serum K 6 mEq ไม�ให� KCl
idividual adjustment with monitoring
THYROID STORM
Underlying hyperthyroidism
Without treatment, inadequate
treatment
Precipitating cause
Precipitating Cause
1. Inappropriate treatment
2. Surgery
3. Infection
4. Injury
5. Radioactive iodine
Principle
1. Supportive treatment
2. Specific treatment
3. Correct prcipitating
Cause
Specific treatment
Inhibit thyroid hormone synthesis
Inhibit thyroid hormone secretion
Inhibit thyroid hormone at
peripheral tissue
PTU
Inh. Synthesis, secretion, periphecal
conversion (T4 T3)
900 - 1200 mg/d x 1-2 d.
(4 x 4, 4 x 6, 2x12)
ฏdose 600 mg/dl
3 x 3 (450 mg/d) x 3 wk Definite
treatment
Iodine
Lugol’s solution (10 mg/drop)
10 drops q 8 hr.
SSKI (50 mg/drop)
4 drops q 8 hr.
Correct precipitating cause
Infection
Surgery
Advice antithyroid drug
Controversy
- blocker : 40 mg q 4 - 6 hr. - oral
(propanolol) 1 mg/min IV drip
Corticosteroid : Dexamethasone 2 mg IV
q 6 hr.
Practical point
1. ในิกรณ ไม�แนิ�ใจว่� Thyroid storm หร+อ severe hyperthyroidism ให�ร�กษแบบ
thyroid strom ไว่�ก�อนิ2. กรให� propanolol ย�ง Controversy
3. ถ้�จะให� corticosteroid ต่ำ�องแนิ�ใจว่�
สูมรถ้คว่บค)มกรต่ำ�ดัเชั่+.อไดั�ดั
4. ถ้�เก�ดั thyroid strom หล�งผู้�ต่ำ�ดัให� พิ�จรณ PTU / MMI rectal
suppository, contrast media injection
5. ต่ำ�องให� Lugol’s solution หร+อ SSKI
หล�งจกให� PTU ไปแล�ว่ 1 ชั่��ว่โมง6. ไม�ต่ำ�องรอผู้ล thyroid function test
Myxedema Coma
Hypothyroidisim
Thyroidectomy scar
History of I 131 treatment
Precipitating cause
1. Infection
2. Sedative drug
3. กรไดั�ร�บนิ�.เกล+อที่ �เป0นิ hypotonicity
4. Cold temperature
Symptoms & signs
Sign of hypothyroidism
Hypothermia
Bradycardia
Hypoventilation
Hyponatremia
Coma
Investigation
Routine lab
TFT, Electrolyte
EKG - low voltage
- Flattening or inverted
T-Waves
Principle
1. Supportive treatment
2. Specific treatment
3. Correct precipitating
Cause
Supportive treatment
Body temperature Correct hypoventilation Correct hyponatremia Coma care Hydrocortisone 300 mg
IV in 24 hr.
Specific treatment
Eltroxin
- 400 - 500 ug IV drip slow Day 1 or
1000 ug NG - tube
- Onset 6 hr.
- ฏdose 100 ug/d ในิว่�นิถ้�ดัไป
Correct precipitating cause
Evidence of infection and
treatment
Stop sedative drug
Advice Medication