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ENDOCRINE EMERGENCIES

ENDOCRINE EMERGENCIES. A. Tuthill. INTRODUCTION (1). Endocrine emergencies comprise approx. 1.5% of all hospital admissions in the UK Diabetes mellitus is by far the most common endocrine disorder encountered in clinical practice - Type 2 diabetes affects 5% population

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ENDOCRINE EMERGENCIES

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  1. ENDOCRINE EMERGENCIES A. Tuthill

  2. INTRODUCTION (1) • Endocrine emergencies comprise approx. 1.5% of all hospital admissions in the UK • Diabetes mellitus is by far the most common endocrine disorder encountered in clinical practice - Type 2 diabetes affects 5% population - Type 1 diabetes affects 0.5 – 1% population

  3. INTRODUCTION (2) • The most common endocrine emergencies therefore relate to diabetes and are 1. Hypoglycaemia 2. Diabetic Ketoacidosis 3. Hyperosmolar Hyperglycaemic State

  4. INTRODUCTION (3) • The other emergencies which are life-threatening and frequently overlooked - Acute adrenal insufficiency - Pituitary apoplexy - Phaeochromocytoma hypertensive crisis - Thyroid storm - Myxoedema coma - Hypo / hypercalcaemia

  5. HYPOGLYCAEMIA • In 2004-5 there were approx. 8,000 hospital admissions related to hypoglycaemia • However there can be up to 90,000 ambulance callouts per year for this condition • ALL UNCONSCIOUS PATIENTS SHOULD BE ASSUMED TO BE HYPOGLYCAEMIC UNTIL PROVEN OTHERWISE

  6. HYPOGLYCAEMIA (1) • Causes : 1. Drugs - insulin/oral hypoglycaemics - alcohol - salicylates - quinine - beta-blockers, pentamidine, disopyramide - prescription errors e.g. chlorpropamide for chlorpromazine

  7. HYPOGLYCAEMIA (2) • Causes : 2. Tumours - Insulinoma - Retroperitoneal sarcomas 3. Miscellaneous - Liver dysfunction - adrenal insufficiency / hypopituitarism - renal failure - myxoedema

  8. HYPOGLYCAEMIA (3) • Presentation : 1. Autonomic (Blood glucose 3.3 – 3.6 mmol/l) - diaphoresis - anxiety - palpitations / tachycardia - tremor - warm feeling

  9. HYPOGLYCAEMIA (4) • Presentation : 2. Neuroglycopenic (Blood glucose <2.6 mmol/l) - confusion - slurred speech - visual disturbances - being uncoordinated - tiredness - focal neurological defects - coma / seizures (usually with glucose <1.5 mmol/l)

  10. HYPOGLYCAEMIA (5) • Hypoglycaemia unawareness occurs in up to 1/3 patients with type 1 diabetes • Conversely, some patients have hypoglycaemic symptoms when their glucose is above the target range (> 7.0 mmol/l) • Patients post total pancreatectomy have more frequent and severe episodes because they have also lost their glucagon producing cells

  11. HYPOGLYCAEMIA (6) • Diagnosis : - Blood glucose - U and E, liver profile - Insulin and C-peptide levels - Sulphonylurea screen - IGF-2

  12. HYPOGLYCAEMIA (7) • Treatment : - If the patient is conscious, treat orally - If unconscious, give 50ml 50% dextrose IV - Glucagon 1mg i.m. - Infusion of 10% glucose - Consider thiamine - Vigilance, Re-education, Support

  13. HIGHS LOWS

  14. DIABETIC KETOACIDOSIS • DKA is a triad of hyperglycaemia, ketosis and acidaemia • Diagnostic criteria (ADA) : - Blood glucose > 13.8 mmol/l - pH < 7.3 - Serum bicarbonate < 18mmol/l, - Anion gap > 10 - Ketonaemia

  15. DIABETIC KETOACIDOSIS (1) • EURODIAB study reported an incidence of DKA in type 1 diabetes of 8.6% • It is the most common cause of death in young people with diabetes and in those > 65 years of age • Precipitants include infection, MI, trauma, drugs (steroids, cocaine, antipsychotics), non-compliance. • It may also be the presenting feature of type 1 diabetes

  16. DIABETIC KETOACIDOSIS (2) • Pathogenesis : - insulin deficiency - increased counter-regulatory hormones (glucagon, catecholamines, cortisol and GH) • This leads to increased glucose production by the liver and decreased utilisation in peripheral tissues. Lipolysis results in ketone body production and acidosis.

  17. DIABETIC KETOACIDOSIS (3) • Clinical Features : - Polyuria - Polydipsia - Weight loss - Vomiting / abdominal pain - Dehydration - Tachypnoea - Altered mental status

  18. DIABETIC KETOACIDOSIS (4) • Laboratory Findings : - Hyperglycaemia (> 13.8 mmol/l) - Hyperosmolality [2x(Na+K) + Urea + Glucose] - Ketones - Widened anion gap metabolic acidosis (pH < 7.3) - Elevated urea and creatinine - Hyperkalaemia - Leucocytosis

  19. DIABETIC KETOACIDOSIS (5) • Management : - FLUIDS - Fluids - Fluids - INSULIN - POTASSIUM - ± ICU admission - Search for precipitant - Education

  20. HYPEROSMOLAR HYPERGLYCAEMIC STATE • Hyperosmolar hyperglycaemic state (HHS) is caused by deficiency of insulin usually in elderly patients; 2/3 have previously undiagnosed diabetes • Mortality up to 50% • Diagnostic criteria: - Blood glucose > 33.3 mmol/l - pH > 7.3 - Serum bicarbonate > 15 mmol/l, - Serum Osmolality > 320mOsm/Kg

  21. HYPEROSMOLAR HYPERGLYCAEMIC STATE • Precipitants : - Infection - Myocardial infarction / cerebrovascular accident - Inadequate insulin treatment / noncompliance - High sugar intake - Other endocrine disorders e.g. acromegaly - Drugs e.g. glucocorticoids, thiazides, loop diuretics, phenytoin

  22. HHS (2) • Clinical Features : - Similar to DKA but history often several days to weeks - As the degree of hyperglycaemia and hyperosmolarity progresses neurologic symptoms are more common including lethargy, focal signs, obtundation and coma - Severe dehydration

  23. HHS (3) • Laboratory Findings : - Hyperglycaemia - Hyperosmolarity [2x(Na+K) + Urea + Glucose] - Hypo or hypernatraemia - Hyperkalaemia

  24. HHS (4) • Management : - FLUIDS - Fluids - INSULIN - POTASSIUM - Anticoagulation - ± ICU admission - Search for precipitant - Education

  25. ACUTE ADRENAL INSUFFICIENCY • Life-threatening emergency • Causes : - Autoimmune - Adrenal TB / haemorrhage / metastases - Hypopituitarism - Drugs e.g. metyrapone, ketoconazole, rifampicin - Interruption of adrenal replacement therapy - Adrenoleucodystrophy

  26. ACUTE ADRENAL INSUFFICIENCY(1) • Clinical Features : - Hypotension (mineralocorticoid deficiency) - Postural hypotension - Nausea and vomiting, weight loss, fatigue - Hypoglycaemia - Hyperpigmentation

  27. ACUTE ADRENAL INSUFFICIENCY(2) • Laboratory Findings: - Hyponatraemia (90%) / hyperkalaemia (65%) - Elevated Urea - Hypoglycaemia - Anaemia (normal MCV) - Metabolic acidosis - Hypocortisolaemia / Failure to respond adequately to synthetic ACTH - ACTH or  -  Plasma renin

  28. ACUTE ADRENAL INSUFFICIENCY(3) • Management : - Intravenous fluids (Saline) - Steroids - Dextrose - Evaluate cause (antibodies, imaging, VLCFA) - Investigate for other endocrinopathies - Steroid alert card / bracelet - Education

  29. PHAEOCHROMOCYTOMA / CATECHOLAMINE CRISIS Phaeochromocytomas are catecholamine secreting tumours of the adrenal medulla < 0.1% Hypertension, but may cause hypertensive emergencies (SBP > 220mmHg or DBP > 120 mmHg) 10% bilateral 10% extra-adrenal 10% malignant 10% familial (Neurofibromatosis, Von Hippel Lindau, MEN 2, SDHD/SDHB mutations)

  30. PHAEOCHROMOCYTOMA / CATECHOLAMINE CRISIS(1) Secretory Products: - Noradrenaline / normetanephrines - Adrenaline / metanephrines - Dopamine

  31. PHAEOCHROMOCYTOMA / CATECHOLAMINE CRISIS(2) Clinical Features : - Hypertension - Anxiety attacks - Sweating and heat intolerance - Flushing / Pallor, palpitations, pounding headaches, pyrexia - Tachycardia / arrhythmias

  32. PHAEOCHROMOCYTOMA / CATECHOLAMINE CRISIS(3) Crisis Precipitants : - Straining - Exercise - Pressure on abdomen - Surgery - Drugs

  33. PHAEOCHROMOCYTOMA / CATECHOLAMINE CRISIS(4) Laboratory Findings : - Hyperglycaemia - Hypokalaemia Investigations : - Urinary catecholamines - Chromogranin A, B - MRI / MIBG

  34. PHAEOCHROMOCYTOMA / CATECHOLAMINE CRISIS(5) Management : - Rehydration - Alpha blockade (Phentolamine / phenoxybenzamine) - LATER, Beta blockade - Surgical resection - Screening for associated conditions

  35. PITUITARY APOPLEXY • Apoplexy refers to infarction of the pituitary gland due either to haemorrhage or ischaemia • Causes : - Spontaneous haemorrhage - Anticoagulant therapy - Head trauma - Radiation therapy - Drugs (Bromocriptine) - Pituitary function testing

  36. PITUITARY APOPLEXY(1) • Rare • 0.6 – 25% cases of treated pituitary adenoma • Clinical Features : - Headaches - Nausea, vomiting - Visual disturbance - Cranial nerve palsy - Meningism

  37. PITUITARY APOPLEXY(2) • Diagnosis : - High degree of suspicion - Brain imaging - Hypo / hypernatraemia may occur - Baseline pituitary function tests - Visual fields

  38. PITUITARY APOPLEXY(3) • Management : - Stabilise the patients (A, B, C) - Hydrocortisone - Fluid balance - Early neurosurgical intervention particularly if significant visual involvement - Reassess pituitary function once acute apoplexy resolved

  39. HYPOCALCAEMIA • Usually the result of failure of PTH secretion or inability to release calcium from bone • Causes : - Hypoparathyroidism (autoimmune, surgical, radiation, infiltration) - Failure of parathyroid development - Failure of PTH secretion (Magnesium deficiency) - Failure of parathyroid action (Pseudohypoparathyroidism)

  40. HYPOCALCAEMIA(1) • Causes : (contd.) - Failure of 1,25 (OH)2D levels (drugs, pancreatitis) - Failure of calcium release from bone (osteomalacia, renal failure, hungry bone syndrome) - Complexing of calcium from the circulation (multiple blood transfusion, pancreatitis)

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