Endocrine Emergency

HYPOGLYCEMIA

WHIPPLES TRIAD

Symptoms consistent with hypoglycemia Neurogenic manifestration Neuroglycopenic manifestration Low plasma glucose Non-diabetic subject <50 mg/dl Diabetic subject <70 mg/dl Relief of symptoms when plasma glucose
concentration is raised to normal level

SYMPTOMS OF HYPOGLYCEMIA
NEUROGENIC (AUTONOMIC) trembling palpitations anxiety hunger nausea tingling

NEUROGLYCOPENIC

difficulty concentrating confusion weakness drowsiness vision changes difficulty speaking headache dizziness tiredness

SEVERITY OF HYPOGLYCEMIA
MILD Autonomic symptoms are present Individual is able to self-treat MODERATE Autonomic and neuroglycopenic symptoms are present Individual is able to self-treat SEVERE Unconsciousness may present Individual requires assistance of another person Plasma glucose is typically < 50 mg/dl

MANAGEMENT OF HYPOGLYCEMIA

Is it true hypoglycemia? What is its cause? Treatment of hypoglycemia Prevention

COMMON CAUSES OF HYPOGLYCEMIA

DIABETIC SUBJECT

Mismatch between

Drug Carbohydrate intake Activity Infection Renal failure

NON-DIABETIC SUBJECT Drug Some kinds of tumor Hormonal deficiency Hepatic or renal failure

MANAGEMENT OF HYPOGLYCEMIA
Capillary blood glucose Confirmed venous blood glucose Identify cause of hypoglycemia* MILD - MODERATE HYPOGLYCEMIA CONSCIOUSNESS SEVERE HYPOGLYCEMIA UNCONSCIOUSNESS IV 50% glucose 50 ml IV 10%Dextrose 80 ml/h Retest BG after 15-20 min Check for recovery Recover Not recover Repeat treatment Follow up BG q 2-4 h in 24 h Adjust IV glucose keep BS >100mg/dl

15-30 g of oral carbohydrate

(100-120 ml of fruit juice or 120-150 ml of regular soda)

Retest BG in 15 min

Repeat treatment if BG still < 70 mg/dl

Have the usual meal or snack to prevent repeated hypoglycemia

Endocrine Emergency

HYPERGLYCEMIC CRISIS

DIAGNOSTIC CRITERIA FOR DKA/HHNS

DKA HHNS

Mild#
Plasma glucose Arterial pH Serum HCO3 Urine ketone Serum Ketone Effective serum osmolarity* Anion gap**
# Be

Moderate Severe
>600 >7.30 >15 small small >320 variable

>250 >250 >250 7.25-7.30 7.00-7.24 <7.00 15-18 <10 10-<15 +ve +ve +ve +ve +ve +ve variable variable variable >10 >12 >12

careful of hypoglycemia during treatment **Anion gap = Na+ (Cl-+HCO3-) * Effective serum osmolarity = 2Na+glucose/18

DKA/HHNS : PRINCIPLE OF TREATMENT

Correction of volume depletion Correction of hyperglycemia Correction of electrolyte imbalances Monitoring Identification of precipitating events

DKA/HHNS : CORRECTION OF VOLUME DEPLETION

DETERMINE VOLUME STATUS AND CORRECTED SERUM SODIUM
STATUS Hypotension Low serum Na Normal serum Na High serum Na Plasma glucose decreased to the level around 250 mg/dl TYPE OF FLUID 0.9%NSS 0.9%NSS 0.45%NSS 0.45%NSS 5%D

Corrected Na= Serum Na+[(BS-100)/100*1.6]

DKA/HHNS : CORRECTION OF HYPERGLYCEMIA

USE SHORT ACTING INSULIN ACCESS BP AND TISSUE PERFUSION
STATUS Normal Hypotension Poor tissue perfusion Plasma glucose decreased to the level around 250 mg/dl ROUTE OF INSULIN THERAPY Intramuscular Intravenous Intravenous Subcutaneous/intravenous

DKA/HHNS : CORRECTION OF ELECTROLYTE IMBALANCES

POTASSIUM LEVEL
LEVEL <3.3 mEq/L 3.3-5.2 mEq/L >5.2 mEq/L ACTION Hold Insulin, K replacement until K>3.3 mEq/L K replacement keep K 4-5 mEq/L FU K next 2 h until K < 5.2 mEq/L

ACIDOSIS
pH >6.9 <6.9 ACTION No NaHCO3 NaHCO3

DKA/HHNS : MONITORING
Time Mental status Temperature Pulse Blood Pressure Respiration Serum glucose Serum ketones Urine ketones Electrolytes Anion gap BUN Creatinine ABG Insulin -unit past hour -route Intake fluid/metabolites -0.45%NSS (ml) past hour -0.9%NSS (ml) past hour -5%dextrose (ml) past hour -KCl (mEq) past hour -Others (HCO3) Urine Output

DKA/HHNS : IDENTIFICATION OF PRECIPITATING EVENTS

Infection Drug: corticosteroids, thiazides, dobutamine New onset of diabetes Discontinuation or inadequate treatment In elderly who unable to take fluids Others: CVA, MI, trauma, pancreatitis

Management of Adult Patient with DKA & HHNS #

Start IV fluid: 1-1.5 L of 0.9%NSS per hour initially + monitoring* IV Fluid
-determine volume status -evaluate corrected Na (see box 1)

Insulin
Access BP and tissue perfusion IM route** RI 10 u IV+10 u IM then 10 u IM /h IV route***

Potassium
If K <3.3 mEq/L**** hold insulin + and give K 20-30 mEq/h until K+>3.3 mEq/L If K >5.2 mEq/L + do not give K + check K every 2 h
+ +

Assess need for bicarbonate In DKA

pH >6.90

RI 0.1 u.kg IV then 0.1 u/kg /h

No NaHCO3
pH <6.90 NaHCO3 100 ml Repeat HCO3 every 2 h until pH>7.00

High Na

Normal Na

Low Na

BP

If plasma glucose does not fall by 50 mg/dl in 1st hour, see box 2 Double insulin dose hourly until glucose falls at least 50-75 mg/dl

0.45%NSS 250-500 ml/h

0.9%NSS 250-500 ml/h

If K+ 3.3 -5.2 mEq/L and normal renal function give K+ 20-30 mEq in each L of IV fluid To keep K+ at 4-5 mEq/L

When plasma glucose reaches 250 mg/dl

Change to 5%D/N 150-200 ml/h + NSS depending on volume status

#

RI 0.1 u/kg SC premeal, ~1-2 hour before stop IV insulin Adjust to keep plasma glucose 150-200 mg/dl
Box 1: Corrected Na= Serum Na+[(BS-100)/100*1.6] Box 2: For IM insulin injection: corrected insulin injection technique and check tissue perfusion For IV insulin infusion: corrected insulin infusion technique

admit to ICU * Identified and treated precipitating factor ** Do not use in hypotension or poor tissue perfusion *** Indicate in hypotension, poor tissue perfusion or not response to IM route **** Cardiac monitoring are needed

Endocrine Emergency

ADRENAL CRISIS

ADRENAL CRISIS : PRESENTING SYMPTOM

Hypotension or Hypotensive shock Alteration of Consciousness:

Hypoglycemia Hyponatremia

ADRENAL CRISIS
SUSPECTED IN PATIENT WHO:

Known case of adrenal insufficiency Prior glucocorticoid therapy Patient with known autoimmune disease Those who display acute symptoms related to the

disease known to cause adrenal insufficiency Postsurgery Pituitary/adrenal Bleeding disorder History of postpartum hemorhage Not response to cathecholamine administration Unexplained hypotension

Proper investigation & management Precipitating cause SUSPICIOUS ADRENAL CRISIS Investigation for diagnosis Cortisol + ACTH level

Other metabolic disorders

Hydrocortisone 100 mg IV stat Cortisol level >20 mcg/dL Unlikely <20 mcg/dL Highly likely Proper treatment

Stop hydrocortisone Hydrocortisone Investigation for 200-300 mg/D other causes

Endocrine Emergency