Download Endocrine Emergency

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
ระดับ Plasma glucose ต่ำกว่ ำ 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
 Good conscious
• Oral intake
• Correct cause of hypoglycemia
• Monitor plasma glucose
Unconscious
 50% glucose 50 ml IV. ตำมด้ วย
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 การวินิจฉัยภาวะ DKA และ HHNS
DKA
Mild
>250
7.25-7.30
15-18
Positive
Positive
Variable
Moderate
>250
7.00-7.24
10-15
Positive
Positive
Variable
Severe
>250
<7.00
<10
Positive
Positive
Variable
HHNS
>600
>7.30
>15
Small
Small
>320
Plasma glucose (mg/dl)
Arterial pH
Serum bicarbonate (mEq/l)
Urine ketones*
Serum ketones*
Effective serum osmolality
(mOsm/kg)
Anion gap±
>10
>12
>12
<12
Alteration in sensorium
Alert
Atert/drowsy
Stupor/coma Stupor/coma
or mental obtundation
*Nitroprusside reaction method; calculation: 2[measured Na (mEq/l)] + glucose (mg/dl)/18;
+
±calculation (Na ) – (HCO3 + CI ) (mEq/I).
ที่มา : ดัดแปลงจาก American 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
Fluid
0.9% Na Cl 1000 - 1500 CC. ในชั่วโมงแรก
1000
CC.ในชั่วโมงที่ 2
500
CC.ในชั่วโมงที่ 3
250
CC.ในชั่วโมงที่ 4 และต่ อไป
- ถ้ ำ Na > 150
- ผู้ป่วยสู งอำยุ
0.45% Na Cl
CVP
Insulin
 Short actig (IV / IM)
- 10 u IV.
- 10 u IV drip / hr. (ผสมใน Na Cl)
 Monitor BS q 1 hr.
Electrolyte q 2-4 hr,
osmolarity, Anion gap
เปลีย่ น 5% DW หรื อ
BS < 300
5% DN/2 125-250 ml/hr.
Insulin 10-12 u Sc. q 4 hr.
หรื 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 ให้ KCl 30 mEq/hr.
serum K 3-4 mEq ให้ KCl 20 mEq/hr.
serum K 4-5 mEq ให้ KCl 15 mEq/hr.
serum K 5-6 mEq ให้ KCl 10 mEq/hr.
serum K 6
mEq ไม่ ให้ 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)

ฏ
dose 600 mg/dl
 3 x 3 (450 mg/d) x 3 wk
treatment
Definite
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. ในกรณีไม่ แน่ ใจว่ ำ Thyroid storm หรื อ
severe hyperthyroidism ให้ รักษำแบบ
thyroid strom ไว้ ก่อน
2. กำรให้ propanolol ยัง Controversy
3. ถ้ ำจะให้ corticosteroid ต้ องแน่ ใจว่ ำ
้ ดี
สามารถควบคุมการติดเชือได้
4. ถ้ ำเกิด thyroid strom หลังผ่ ำตัดให้
พิจำรณำ PTU / MMI rectal
suppository, contrast media injection
5. ต้ องให้ Lugol’s solution หรื อ SSKI
หลังจำกให้ PTU ไปแล้ว 1 ชั่วโมง
6. ไม่ ต้องรอผล thyroid function test
Myxedema Coma
 Hypothyroidisim
 Thyroidectomy scar
 History of I 131 treatment
Precipitating cause
1. Infection
2. Sedative drug
3. กำรได้ รับนำ้ เกลือที่เป็ น 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.
- ฏ dose 100 ug/d ในวันถัดไป
Correct precipitating cause
 Evidence of infection and
treatment
 Stop sedative drug
 Advice Medication