Endocrine Emergencies

Indah D. Pratiwi
Dept. of Emergency Nursing
The Endocrine System
• It’s complicated.
• Regulatory proteins
secreted by the body to
control housekeeping
functions for the body.
• Some parts malfunction
more commonly,
creating life-threatening
problems.
 Why should I pay attention?
• Some endocrine emergencies are very
common…you will see these.
• DKA, Hypoglycemia
• Endocrine system controls basic life
functions…when things go bad, they go really
bad.
• You’re the first medical personnel to see that
patient!
 Do I Have to Make the Diagnosis?

• No
• Often supportive treatment is all that is
necessary
• Good to have this in the back of your mind
for the “weird” cases
 Hypoglycemia
Presenting Signs & Symptoms
• Low blood sugar occurs commonly.
• It is life-threatening!
• Many different presentations:
• Depressed sensorium (52%)
• Other AMS (30%)
• Hyperadrenergic symptoms (8%)
• Seizure (7%)
• Focal neuro deficit (2%)
 Hypoglycemia
Who gets it & why?
Who? Why?
• Diabetics! • Hypoglycemic agents
• Alcoholics • Lack of reserve sugar
• Kids • Unique physiology
• Septic patients • All used up from stress
• Overdose patients • Drugs alter metabolism
• Adrenal crisis patients • Body unable to function
• Hypothyroid patients normally
 Hypoglycemia
Diagnosis
• Just check their serum glucose!
• Glucose < 50mg/dL is text definition.
 Hypoglycemia
Treatment
• Give glucose back
• IV dextrose
• Adult: 1cc/kg of D50 (50% dextrose soln)
• Kid: 2-4cc/kg of D25
• Newborn: 5-10cc/kg of D10
• IM/IV glucagon
• 1mg IM
• Glucocorticoids
 DKA: Diabetic Ketoacidosis
• It’s what happens when you get really
stressed and insulin doesn’t work!
• Who gets it?
• Diabetics!
• Most common in younger, type 1 patients
• Frequently occurs in older, type 2 patients
• 25% cases are undiagnosed diabetics.

• When severe, it can manifest neuro

symptoms.
 Diabetic Ketoacidosis
What really happens?
• Something creates a stress/catecholamine state.
• The body cannot use glucose to respond.
• Plan B.
• Broken glucose metabolism + plan B = DKA.
 Diabetic Ketoacidosis
What really happens?
• There is an initial insult that creates a
catecholamine stress.
• Infection
• CVA
• AMI
• Treating DKA is pretty easy. Figuring out the
precipitating cause is sometimes hard.
 Diabetic Ketoacidosis
What really happens?
• Glucose can’t get into cells! Relative
hyperglycemia results from the stress
response.
• Body makes more new glucose.
• A hyperosmolar state is the result.
• Osmotic diuresis, vomiting, decreased po intake.
• Acidosis eventually occurs
• K+, PO4-, bicarbonate loss
 Diabetic Ketoacidosis
What really happens?
• The body goes to plan B lipolysis.
• This creates energy…and ketoacids.
• The already acidemic body gets bombarded with
more acid!
 Diabetic Ketoacidosis
A Complex Process

cannot
use
acidosis
glucose

DKA

increased
ketones
 Diabetic Ketoacidosis
Diagnosis & Treatment
• Clinical suspicion in the right setting,
confirmation with lab testing.
• Prehospital treatment:
• Fluids, fluids, fluids!
• IV access
• Monitor cardiac activity
• What is causing it????
 Hyperosmolar Non-Ketotic Syndrome
(HNS)
• Traditionally occurs in older, diabetics.
• Frequently presents as AMS, fatigue, anorexia,
or weakness.
• Usually has an initiating event: new meds,
decreased water intake, etc.
 HNS
What really happens?
• The initiating insult leads to unchecked
hyperglycemia.
• Hyperosmolar state ensues…
• …leads to incredible diuresis of 9-15 liters!
• End result: dehydrated, electrolyte imbalances,
hyperglycemia.
 HNS
Diagnosis & Treatment
• Poorly understand why these patients avoid
ketoacidemia.
• Diagnosis confirmed with marked hyperglycemia in
the right clinical setting.
• Treatment:
• Fluids, fluids, fluids!
• Supportive care.
 Hyperthyroidism &
Thyroid Storm
• Extreme hyperthyroidism…hypermetabolic state:
• Tachycardia, hypertension, tremor, fever, etc.
• Treatment is symptomatic and aimed at decreasing
peripheral activation of thyroid hormone.
• Prehospital treatment is oxygen, IVF.
 Adrenal Crisis
• What does the adrenal normally do?
• Medulla makes catecholamines (E & NE)
• Cortex makes lots of important hormones:
• Glucocorticoids - BP, glucose metabolism
• Mineralocorticoid - BP, salt/water homeostasis
• Androgenic steroids - secondary sex characteristics
 Adrenal Crisis
Clinical Picture
• What do you see when it doesn’t work?
• Anorexia, nausea, vomiting
• Weakness, fatigue, lethargy, AMS
• Hypoglycemia
• Hypotension, circulatory collapse
• Hyponatremia with severe dehydration
• Hyperkalemia (not usually severe)
• Brownish pigmentation (no feedback suppress.)
• Decreased aldosterone & cortisol.
 Adrenal Crisis
How do you get it?
• Iatrogenic • Infection
• Trauma • Pregnancy
• Surgery • Hyperthyroidism
• Burns • Drugs (anasthetics)
 Adrenal Crisis
Diagnosis & Treatment
• Diagnosis is clinical and supported by lab
data.
• Prehospital treatment:
• Correct hypotension
• Correct hypoglycemia
• Other supportive measures.
• Patient will receive hydrocortisone at ED.
 In Summary

• Complications of diabetes can be quite

variable
• Not every accu-check reading high is DKA
• Be aware of the cold, bradycardic and
hypotensive patients
• Chronic steroids + hypotension  Think
adrenal crisis