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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.

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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
Hypoglycemia

ระดับ Plasma glucose ต่ำกว่า 50 mg/dl “Whipple’s triad”

- low plasma glucose

- Neuroglycopenia

- Corrected by glucose


Classification
Classification

  • Fasting hypoglycemia

    - underproduction

    - overutilization

  • Post prandial hypoglycemia


Underproduction of glucose
Underproduction of glucose

  • Hormone deficiency

  • Enzyme defect

  • Substrate deficiency

  • Acquired liver disease

  • Drug : alcohol, propanolol,

    salicylate,quinine etc.


Overutilization of glucose
Overutilization of glucose

Hyperinsulinism

  • Insulinoma

  • Exogenous insulin

  • Sulfonylurea

    Appropriate insulin

  • Extrapancreatic tumor

  • Carnitine deficiency


Treatment
Treatment

  • Good conscious

  • Oral intake

  • Correct cause of hypoglycemia

  • Monitor plasma glucose


Unconscious
Unconscious

  • 50% glucose 50 ml IV. ตามด้วย

    10% Dextrose intravenous drip

    125 - 250 ml/hr.

  • Glucagon 1 mg IM


Diabetic emergency
Diabetic Emergency

  • DKA

  • HONC

  • Focal hyperglycemia

    seizure


DKA

  • Kussmaul’s breathing

  • Polyuria, polydipsia, polyphagia

  • Alteration of conscious

  • Other : dehydration, nausea, abdominal pain etc.


Diagnosis
Diagnosis

  • Plasma glucose > 300-350 mg/dl

  • Wide anion gap acidosis

  • Serum Ketone + ve

  • not necessary


HONC

  • Neurological Sign & Symptoms

  • Severe Dehydration

  • Evidence of infection


Diagnosis1
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


Treatment1
Treatment

  • Initial lab

    CBC, UA, BS, BUN, Cr,

    Electrolyte, ketone, ABG.

    Calculated osmolarity

    Septic work up


Fluid

0.9% Na Cl 1000 - 1500 CC. ในชั่วโมงแรก1000 CC.ในชั่วโมงที่ 2500 CC.ในชั่วโมงที่ 3 250 CC.ในชั่วโมงที่ 4 และต่อไป- ถ้า Na > 150 0.45% Na Cl- ผู้ป่วยสูงอายุ CVP


Insulin
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


BS < 300 เปลี่ยน 5%DW หรือ 5% DN/2 125-250 ml/hr. Insulin 10-12 u Sc. q 4 hr. หรือ IV.drip low dose (2 u/hr) NaHCO3 - pH < 6.9, 7.0 - Cardiovascular instability : 100 mEq IV drip in 1 hr.


Potassium
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 ไม่ให้ KCl

idividual adjustment with monitoring


Thyroid storm
THYROID STORM

  • Underlying hyperthyroidism

  • Without treatment, inadequate

    treatment

  • Precipitating cause


Precipitating cause
Precipitating Cause

1. Inappropriate treatment

2. Surgery

3. Infection

4. Injury

5. Radioactive iodine


Principle
Principle

1. Supportive treatment

2. Specific treatment

3. Correct prcipitating Cause


Specific treatment
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 Definite

    treatment


Iodine
Iodine

  • Lugol’s solution (10 mg/drop) 10 drops q 8 hr.

  • SSKI (50 mg/drop) 4 drops q 8 hr.


Correct precipitating cause
Correct precipitating cause

  • Infection

  • Surgery

  • Advice antithyroid drug


Controversy
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
Practical point

1. ในกรณีไม่แน่ใจว่า Thyroid storm หรือ

severe hyperthyroidism ให้รักษาแบบ

thyroid strom ไว้ก่อน

2. การให้ propanolol ยัง Controversy

3. ถ้าจะให้ corticosteroid ต้องแน่ใจว่า

สามารถควบคุมการติดเชื้อได้ดี


4. ถ้าเกิด thyroid strom หลังผ่าตัดให้

พิจารณา PTU / MMI rectal

suppository, contrast media injection

5. ต้องให้ Lugol’s solution หรือ SSKI

หลังจากให้ PTU ไปแล้ว 1 ชั่วโมง

6. ไม่ต้องรอผล thyroid function test


Myxedema coma
Myxedema Coma

  • Hypothyroidisim

  • Thyroidectomy scar

  • History of I 131 treatment


Precipitating cause1
Precipitating cause

1. Infection

2. Sedative drug

3. การได้รับน้ำเกลือที่เป็น hypotonicity

4. Cold temperature


Symptoms signs
Symptoms & signs

  • Sign of hypothyroidism

  • Hypothermia

  • Bradycardia

  • Hypoventilation

  • Hyponatremia

  • Coma


Investigation
Investigation

  • Routine lab

  • TFT, Electrolyte

  • EKG - low voltage

    - Flattening or inverted

    T-Waves


Principle1
Principle

1. Supportive treatment

2. Specific treatment

3. Correct precipitating Cause


Supportive treatment
Supportive treatment

  • Body temperature

  • Correct hypoventilation

  • Correct hyponatremia

  • Coma care

  • Hydrocortisone 300 mg

    IV in 24 hr.


Specific treatment1
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 cause1
Correct precipitating cause

  • Evidence of infection and

    treatment

  • Stop sedative drug

  • Advice Medication


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