Endocrinal emergencies
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Endocrinal emergencies. Dr. Miada Mahmoud Rady. Hyperosmolar Non ketotic coma. Also known as hyperglycemic , hyperosmolar ,Non ketotic coma ( HHNC). Occurs in neglected , uncontrolled diabetes esp. in elderly. Occurs primarily in type 2 diabetes .

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Endocrinal emergencies

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Endocrinal emergencies

Endocrinal emergencies

Dr. Miada Mahmoud Rady


Hyperosmolar non ketotic coma

Hyperosmolar Non ketotic coma

  • Also known as hyperglycemic , hyperosmolar ,Non ketotic coma ( HHNC).

  • Occurs in neglected , uncontrolled diabetes esp. in elderly.

  • Occurs primarily in type 2 diabetes .

  • Predisposing factor : stressful condition which impairs fluid intake e.g. infection , operation , stroke , MI .


Endocrinal emergencies

  • Pathogenesis :

  • Stressful conditions → secretion of hormones that counteract effect the of insulin→ hyperglycemia.

  • Impaired ability to drink along with hyperglycemia causes hyperosmolarity.

  • Characterized by : hyperglycemia , hyperosmolarity and no significant ketosis.


Endocrinal emergencies

  • Clinical presentation :

  • Symptoms of uncontrolled D.M

  • Sever dehydration.

  • Neurologic changes may be found, including:

    i.Drowsiness.

    ii.Delirium and coma

    iii.Focal or generalized seizures

    iv.Visual and sensory disturbances

    v.Hemiparesis

Neurological symptoms occurs more with HONK


Endocrinal emergencies

Stroke and MI can cause and result from HONK

  • Laboratory :

  • Hyperglycemia > 600 mg /dl.

  • Hyperosmolarity ( ↑Na conc.).

  • No ketosis.

  • Complication :

  • Increased blood viscosity which increase liability to cerebrovascular accident and myocardial infarction.


Endocrinal emergencies

  • Management :

  • Airway management is the top priority.

  • Endotracheal intubation may be indicated for comatose patients.

  • Cervical spine immobilization should be used for all unresponsive patients found lying down.

  • Large-bore IV access should be gained as soon as possible.


Endocrinal emergencies

  • Obtain a blood glucose level as soon as possible.

  • A bolus of 500 mL 0.9% NS is appropriate for nearly all adults who are clinically dehydrated.

  • In patients with a history of congestive heart failure and/or renal insufficiency, a 250-mL bolus may be more appropriate.

  • Administer 12.5 to 25 g of D50 if the glucose level is less than 60 to 80 mg/dL (depending on local protocols).


Adrenal gland

4 s

Adrenal gland

  • located above kidney ( suprarenal gland ) .

  • Consists of two parts :

  • Hormones secreted and their function :

  • cortisol → sugar→ increase BMR using fat and protein for energy .

  • Aldestorone → salt → Na and water reabsorption (↑ Na ) , K excretion ( ↓ K ).


Endocrinal emergencies

  • Androgens→ sex → sex hormones .

  • Adrenaline and noradrenaline → stress→ stimulates sympathetic nervous system .

  • Cortisol primary role is to assist with the response to stress, but it also:

    a.Helps to maintain blood pressure and cardiovascular function

    b.Regulates the metabolism of carbohydrates, proteins, and fats

    c.Modulates glucose levels

    d.Slows the inflammatory response


Addison disease

Addison disease

  • Primary suprarenal failure

  • Etiology :decreased function of the adrenal cortex with decreased production of cortisol and aldestorone .

  • Pathophysiology : occurs when 90% of both glands are destroyed or atrophied .

  • Clinical presentation :

  • develops over several months

  • usually well tolerated

  • May present with Addison crises ( uncommon)


Clinical picture of addison disease

clinical picture of Addison disease


Endocrinal emergencies

  • Management :

  • Address ABCS .

  • Aggressive fluid therapy.

    • Hydrocortisone is indicated in the acute management of a crisis.


Secondary adrenal insufficiency

Secondary adrenal insufficiency

  • Pathophysiology :

    • lack of ACTH secretion from the pituitary gland

  • sudden withdrawal of corticosteroids in patient on chronic steroid therapy.

  • Presentation :

    • May appear suddenly (addisonian crisis)

    • Chief manifestation is shock

    • Symptoms may also include:

      • Confusion

      • Low blood pressure

      • Severe pain and/or vomiting


Endocrinal emergencies

  • Management :

  • Address ABCS .

  • Aggressive fluid therapy.

    • Hydrocortisone is indicated in the acute management of a crisis.


Cushing syndrome

Cushing syndrome

  • Pathophysiology :

    Caused by:

  • Excess cortisol production by the adrenal glands :

  • Example: Tumors of the pituitary or adrenal cortex.

  • Excessive and prolonged use of cortisol or other corticosteroid hormones :

  • Example: treatment of asthma .


Endocrinal emergencies

  • characteristic changes:

  • Metabolismof carbohydrate, protein, and fat is disturbed.

    (a)Blood glucose level rises.

  • Protein synthesis is impaired.

    (a)Body proteins are broken down.

  • Leads to loss of muscle fibers and muscle weakness.

  • Bones become weaker and more susceptible to fracture


Signs and symptoms

signs and symptoms

  • Weakness and fatigue

  • Depression and mood swings

  • Increased thirst and urination

  • High blood glucose level

  • Weight gain

    (a)Abdomen

    (b)Face (“moon face”)

    (c)Neck

    (d)Upper back (“buffalo hump”)


Endocrinal emergencies

  • Thinning of the skin

    (a)Easy bruising

    (b)Pink or purple stretch marks (striae)

  • Increased acne, facial hair growth, and scalp hair loss in women, and cessation of menstrual periods

  • Darkening of skin of the neck

  • Obesity and poor growth in height in children


Management

Management

  • Assess and manage ABCs.

  • Prehospital treatment is generally supportive.

  • Obtain blood glucose level, and administer D50 if indicated.


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