Diabetic and Endocrine

Emergencies

Diabetes

Type I

Usually presents in young patients

Genetic, autoimmune, and/or viral factors
cause pancreatic beta islet cell destruction
leading to insulin deficiency
Hyperglycemia occurs and can progress to
ketoacidosis if insulin isnt given
Symptoms are polyuria, weight loss,
fatigue

Diabetes

Type II

Occurs in older adults

Insulin production may be OK, but the cells are
insulin resistant
Has genetic ties, but diet and obesity determine
the age of onset
Treated with diet, oral hypoglycemics, and insulin

Other causes of diabetes: malnutrition,

pancreatitis, endocrine dx, steroid use

Diabetes

Stress-induced hyperglycemia

Can occur in any critically ill patient

Tight control of blood sugar with insulin improves survival

Hypoglycemia

Occurs when BS is <70ish

Suspect in any patient with a sudden change in mental state
or neurologic fx
Can be caused by a problem with diabetic tx
Can also be caused by a variety of other conditions

Malnutrition
Systemic dx (liver dx, sepsis, infection, hypothermia, adrenal
failure, hypopituitarism)
Poisoning/drug toxicity
Insulin-secreting tumors

Diabetes

Hypoglycemia

Clinical features:

Tremor/sweating
Progressive confusion
Seizures
Coma/irreversible neurologic damage

Treatment

Glucose drink or carb snack if conscious

IV glucose if unconscious

Diabetes

Diabetic ketoacidosis

Occurs with type I diabetes usually from infection,

MI, or pancreatitis
Insulin deficiency prevents the cells from taking
glucose upthe kidneys excrete glucose as it
builds up in the blood which takes water with
itin the meantime, the cells begin to metabolize
fat for energy, which produces ketoacids
Clinical presentation: hyperventilation and
hypotension/hypoperfusion

Diabetes

Ketoacidosis

Diagnosis

Blood sugar
Urine dipstick
Electrolytes
ABG

Management

Fluid resuscitation with NS to correct hypovolemia

Insulin infusion to reduce blood sugar
Electrolyte replacement: especially potassium
Acidosis should resolve with fluid and insulin therapy
General: O2, ATB, NG tube

Diabetes

Hyperosmolar non-ketotic coma (HONK)

Less common than DKA but has much

higher mortality (~50%)
Occurs in elderly patients with Type II who
have sufficienct insulin production to
prevent fat metabolism but not
hyperglycemia
Osmotic diuresis leads to dehydration and
hyperosmolality, but not ketoacidosis

Diabetes

HONK

Clinical features: anorexia, malaise, polyuria,

weakness, confusion, seizures, coma
Diagnosis is based on blood sugar and
hyperosmolality
Management

Rehydration with NS but more gradually than with DKA

Anticoagulants to prevent dehydration-induced emboli

Lactic acidosis

Occurs in Type II diabetics treated with

Glucophage

Endocrine Emergencies

Thyroid emergencies

Thyrotoxic crisis is a life-threatening

hypermetabolic emergency
Precipitated by infection, surgery, diabetes, labor,
radioiodine therapy, and iodinated contrast media
Mortality is ~25%
General management

ID and tx the cause

Correct dehydration/electrolyte abnormalities
Avoid aspirin
Cool the patient down/sedate to reduce agitation

Endocrine Emergencies

Clinical features of severe hyperthyroid

CNS: poor concentration, irritability,

confusion, seizures, coma
Eyes: lid lag, bulging eyes
Peripheral: tremors, goiter, tachycardia,
jaundice, N&V, heart failure, atrial fib,
diarrhea, muscle rigidity/spasm

Endocrine

Thyrotoxic emergency

Specific therapy

Beta blockers: blocks effect of thyroid to

reduce HR, HTN, fever, and tremor
Thiourea derivatives: block T4 synthesis
Prevention of T4 release: iodine solutions,
lithium, dexamethasone

Endocrine

Severe hypothyroidism

Occurs with complications to pre-existing

hypothyroidism
Causes hypothermia, coma, and
hypotension
Usually affects elderly females with
unrecognized hypothyroidism or patients
who fail to take thyroid replacements

Endocrine

Hypothyroidism: clinical features

CNS: lassitude, apathy, coma, seizures

Facial: thin hair, puffy eyes, coarse dry skin,
macroglossia
Peripheral: hoarse voice, goiter, bradycarida,
weight gain, constipation, urinary retention,
peripheral edema, bradykinesia,
hypoventilation/hypoxia, low voltage EKG, flat T
waves, hypoglycemia, hyponatremia

Endocrine

Hypothyroidism

Management

Rewarm patient
Support respiratory system
Correct hypoglycemia
IV thyroxine (T4)

Sick euthyroid syndrome

Not due to a thyroid disorder

Low T4 binding protein and altered T4 metabolism
cause this

Endocrine

Adrenal emergencies

Adrenocortical insufficiency

Reduced cortisol (aldosterone) production by the

adrenal cortex
Causes

Adrenal gland destruction

Addisons dx
Surgical removal
Adrenal infarction
Infection
Infiltration (eg-tumors)
Hemorrhage
Secondary
Pituitary damage/infarction/hemorrhage
Sudden exogenous steroid removal

Endocrine

Causes of adrenal insufficiency

Hypothalamus destruction
Drugs

Inhibit steroid production

Increase hepatic metabolism

Critical illness

Endocrine

Clinical presentation of adrenal

Acute (Addisonian) crises

Precipitated by stress in patients with unrecognized

adrenal insufficiency, following sepsis, or following
adrenal hemorrhage
Pituitary infarction also presents the same way
Apathy, hypoglycemia, hypotension, coma
Suspect on all patients in shock if the cause is not
apparent

Chronic deficiency

Fatigue, weakness, weight loss, fever, and nausea

Hyperpigmentation from excessive melanocyte
stimulating hormone production
Body hair loss in females from reduced androgen
production

Endocrine

Adrenal insufficiency

Investigation

Low baseline cortisol confirms the diagnosis

Hyponatremia, hypoglycemia, hypercalcemia,
eosinophilia are common but not diagnostic
ACTH is high in primary adrenal insufficiency and low in
secondary adrenal insufficiency

Treatment

If in shock, tx the shock condition (fluids/inotropes)

High dose corticosteroids b/c baseline cortisol levels are
low
Tx any infection
Tx hypoglycemia with glucose

Endocrine

Adrenocortical excess

Cushings syndrome (steroid use) and

Cushings dx (pituitary tumor) increase
cortisol levels
Moon face, easily bruised skin, HTN,
diabetes, osteoporosis, central obesity, and
hypokalemia
Can also have excess aldosterone secretion
with adrenal adenoma

Endocrine

Other endocrine emergencies

Hypopituitary crisis

Follows pituitary trauma/tumor/hemorrhage/ infarction

Reduced anterior pituitary hormone secretion causes adrenal
and thyroid insufficiency and hypogonadism
Decreased ADH release from posterior pituitary causes diabetes
insipidus with thirst, dehydration, and severe polyuria

Pheochromocytomas

Rare, benign adrenal tumors that release catecholamines

Often familial and there are usually other endocrine tumors
Drugs, surgery, and certain foods can bring on a crisis
HA, sweating, flushing, arrhythmias, HTN, increased plasma
catecholamines
Treat with alpha blockers, beta blockers, and surgery