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Lndocr|ne Lmergenc|es

8oberL C. Pyzy, Mu, lCC




D|sc|osures

1. MPA - ConsulLanL for keysLone lCu
2. up1ouaLe - Ponorarlum
Cb[ecnves
- 8ecognlze Lhe cllnlcal presenLauons of
endocrlne emergencles lnvolvlng Lhe
pancreas, Lhyrold, adrenal, and plLulLary
glands
- Apply Lhe approach Lo laboraLory Lesung
necessary for Lhe dlagnosls and
managemenL of Lhese condluons ln Lhe
lnLenslve care unlL
- uullze Lhe LreaLmenL for each endocrlne
emergency


D|abenc ketoac|dos|s (DkA) vs. nyperosmo|ar
nyperg|ycem|a Syndrome (nnS)
ukA - glucose usually < 800 mg/dL
keLonemla, Anlon gap acldosls
AC = [na
+
] - ([Cl
-
] + [PCC
3
-
])
ulabeLes Care 2006, 29:2739-2748.

DkA: resentanon
Csmouc dluresls
LxLracellular uld volume depleuon
PypoLenslon
SympLoms - polyurla, polydlpsla, Lachycardla, leLhargy
Acldosls
uecreased sensorlum
n/v, Abdomlnal paln, kussmaul's 8esplrauon,
frulLy breaLh
noncompllance, lnfecuon, ue novo
keLosls udx - LLCP and SLarvauon
DkA: Laboratory
Pyperglycemla
urlne/serum keLones
uecreased PCC
3
-
LlevaLed AC
rerenal azoLemla
LlevaLed Amylase and Llpase
Pyperkalemla - osmouc shllng
uesplLe LoLal body declL
Sodlum varlable
A8C - Pypocapnla (compensaLory), Acldemla
DkA: 1reatment
volume expanslon - llLers down nS
lnsulln
8olus 0.10-013 u/kg
lv lnfuslon 0.10 u/kg/h
Coal Lo lower glucose 30 mg/dL/hour
Cnce lnLravascular volume resLored and glucose < 200
change Lo u3 0.43 sallne
Measure glucose hourly
llnger suck may be lower Lhan venous lf hypoLenslve
Measure elecLrolyLes every 2-4 hours - lollow AC
DkA: 1reatment
Sodlum 8lcarb - besL avolded unless pP<7.00
oLasslum drops and wlll llkely need
supplemenLauon
C
4
drops buL needs replacemenL only lf severe
(<1.0 )
Cnce AC normallzes - change Lo SC regular lnsulln
SLop dexLrose and lv lnsulln 30 mlnuLes laLer

nyperosmo|ar Nonketonc State (nNS)
PCnk - hyperosmolar nonkeLouc syndrome
no keLosls - AC noL elevaLe
uehydrauon - glucosurla
very hlgh glucose
Clder, Lype ll dlabeucs
Sodlum aecLed by hyperglycemla
Na
corrected
mLq]L = Na
measured
mLq]L + [(8|ood g|ucose mg]dL - 100) x 1.S0
nnS 1reatment
vlgorous volume replacemenL
lree WaLer ueclL
[0.6 x kg] x [(na
+
measured]140) - 1]
[70 x 0.6] x [(168 / 140) - 1]
42 x [1.2 - 1]
= 8.4 L
lnsulln drlp
Palf normal sallne once lnLravascular volume has been
replaced
Wh|ch of the fo||ow|ng |s true regard|ng
nght (80-110) G|ycem|c Contro|?
1. 1lghL glycemlc conLrol was noL shown Lo have a morLallLy
beneL ln posL-operauve cardlac pauenLs.
2. 1lghL glycemlc conLrol resulLs ln fewer hypoglycemlc
reacuons.
3. 1lghL glycemlc conLrol was shown ln Lhe nlCL-SuCA8 Lrlal
Lo have a hlgher morLallLy.
4. 1lghL glycemlc conLrol beneLs pauenLs wlLh sepsls Lhe
mosL.
3. 1lghL glycemlc conLrol proLocols are mandaLed by CMS.
G|ucose Contro| |n the ICU
1lghL glycemlc conLrol (80-110 mg/dL)
lnlual reporLs of lmproved cllnlcal ouLcomes followed
by reporLs of lncrease hypoglycemlc reacuons
nlCL-SuCA8 sLudy
lncreased 90 day morLallLy ln ughL conLrol group
1rauma and CS subgroups dld show beneL
ConLrol 8S around 140 mg/dL
Lower Lhan ln Lhe pasL
NICL-SUGAk
NEJM 2009; 360:1283
nypog|ycem|a
<60 mg/dL
Adrenerglc response produces nervousness,
Lremulousness, Lachycardla, dlaphoresls
Severe - selzures
Common lCu causes lnclude:
hepauc fallure, renal fallure, sepsls, adrenal
lnsumclency, leukemla, lymphoma, Lumors lncludlng
hepaLoma or pancreauc lsleL beLa-cell Lumor
drugs such as beLa-blockers, or penLamldlne
u30 buL lf refracLory
Clucagon, Pydrocorusone, CcLreoude
A|| of the fo||ow|ng statements are true
regard|ng myxedema coma, except
1. reclplLaLed by sLress, cold exposure, oplaLes
2. 1reaLed only when Lhe dlagnosls ls conrmed
by lab Lesung
3. Capable of produclng hypercapnla
4. More common ln women
3. ls a cause of euvolemlc hyponaLremla

Myxedema Coma
CnS depresslon
uelayed u18s, hypoLhermla, bradycardla, dry doughy
skln, hyperglossla
PyponaLremla - lmpalred P
2
0 excreuon
Anemla - nC/nC
Pypercapnla
Pyperllpldemla
LlevaLed Ck
Pypoglycemla - alone or wlLh adrenal lnsumclency
Women > Men
Myxedema Coma: Causes
noncompllance
S/p l
131
ablauon
urugs - amlodarone, 1u, llLhlum, sulfonamldes
reclplLanLs
Cold exposure
Sedauves especlally oplaLes
SLress lnfecuon, AMl
Myxedema Coma - 1reatment
8ased on cllnlcal susplclon
uraw labs Lhen LreaL
1SP, free 14, corusol, corLrosyn sumulauon LesL
lv Lhyroxlne 300 ug load
ually 30-100 ug/d
Lmplrlcally LreaL posslble concomlLanL adrenal lnsumclency
Pydrocorusone 300 mg/d
Supporuve measures lnclude - lnLubauon for alrway
proLecuon, nuLrluon
40 aurlbuLable morLallLy
Luthyro|d S|ck Syndrome
Low serum 13
uecreased converslon of r13 Lo 13
14 may be low
1SP may be hlgh, low or normal
lree 14 ls nC8MAL
no LreaLmenL ls requlred
A SS year o|d women presents w|th d|aphores|s,
atr|a| hbr|||anon, tremor and exoptha|mus. When
treanng th|s panent, wh|ch agent shou|d be he|d
unn| the others are g|ven?
1. lodlne
!" #-blockers
3. 1u
4. MeLhlmazole
3. Pydrocorusone
1hyro|d Storm
uenluon lncludes slgnlcanL cardlac or neurologlc
manlfesLauons
Cardlac - ALrlal brlllauon, A. uuer, Sv1
neuro - Lremor, dellrlum, sLupor, coma
P1n, Lachycardla, anxleLy, n/v/u,
heaL lnLol., abdomlnal paln, ne halr,
hyperreexla, exophLhalmos
ApaLheuc hyperLhyroldlsm - elderly

1hyro|d Storm
Craves ulsease - mosL common cause
1hyrold sLorm can be preclplLaLed by sLress
Surgery, pregnancy, Lrauma, acuLe lllness

1hyro|d Storm - D|agnos|s
lncreased 13 and 14, low 1SP.
13 LhyroLoxlcosls - uncommon varlanL
13 levels are elevaLed buL 14 levels remaln normal.
CenLral hyperLhyroldlsm - leasL common
1SP, 13 and 14 all elevaLed.
1hyro|d Storm - 1reatment
Cllnlcal dlagnosls - draw labs buL don'L walL
8lock Lhyrold hormone synLhesls
ropylLhlouracll (1u) 200 mg every four hours or
meLhlmazole 20 mg every 4-6 hours
8lock Lhyrold hormone release
lodlne: SSkl or Lugol's soluuon
Al1L8 blocklng synLhesls
uecrease converslon of 14 Lo 13
1u, hydrocorusone, propranolol
erlpheral hyperadrenerglc Sx - #-blockers
A|| of the fo||ow|ng are potenna| causes of
adrena| |nsumc|ency, except
1. LLomldaLe
2. osL-arLum sLaLe
3. keLoconazole
4. lsonlazld
3. Sarcoldosls
Adrena| Insumc|ency - Causes
rlmary - Adrenal gland fallure
Addlson's dlsease, bllaLeral adrenal hemorrhage, abrupL
wlLhdrawal of exogenously admlnlsLered corucosLerolds,
Luberculosls, sepuc shock, menlngococcemla, meLasLauc
mallgnancy, amyloldosls
urugs - eLomldaLe and keLoconazole
Lack hyperplgmenLauon, dehydrauon, hyperkalemla
Adrena| Insumc|ency - Causes
Secondary - lLulLary - lack of AC1P
Cranlopharyngeoma, posL-operauve compllcauon
osL-parLum hypoplLulLarlsm (Sheehan's
syndrome)
lnlLrauve dlseases-hemochromaLosls,
sarcoldosls, hlsuocyLosls or hlsLoplasmols,
Luberculosls
WlLhdrawal of exogenously admlnlsLered
corucosLerolds
Adrena| Cr|s|s - resentanon
Cen Lrlggered by physlologlc sLress
1rauma, surgery or acuLe medlcal lllness
PypoLenslon, nausea, vomlung, faugue, anorexla,
depresslon, amenorrhea
8llaLeral adrenal hemorrhage or lnfarcuon
Abdomlnal, ank, lower back or chesL paln
8lsks - anucoagulauon, posL-operauve sLaLe
LaboraLory abnormallues
Pypoglycemla, hyponaLremla, hyperkalemla, eoslnophllla
Adrena| Insumc|ency
1oLal Corusol level
>13 rules ouL lf unsLressed
<3 ls speclc buL noL sensluve
<10 62 sensluve, 77 speclc
Pypoalbumlnemla = greaLer free corusol level
nL!M 2004, 330:1629
Cortrosyn snm test
useful lf noL sepuc
230 ug of corLrosyn Lhen 30-60 mlnuLes laLer
lncrease ln LoLal corusol < 9 ug/dL or an absoluLe level less
Lhan 20 ug/dL may be lndlcauve of relauve adrenal
lnsumclency
uexameLhasone (10 mg) slngle dose
So LhaL Lhe laboraLory analysls ls noL alLered, as wlLh
hydrocorusone
Adrena| Insumc|ency - 1reatment
lnlual dose of 200 mg of lv hydrocorusone
1hen 100 mg every 6 hours
lv nS Lo correcL volume conLracuon
PypoLonlc ulds should noL be admlnlsLered
Can worsen hyponaLremla
Mlneralocorucold admlnlsLrauon noL requlred
osslble excepuon of sepuc pauenLs
Adrena| Insumc|ency |n Seps|s: CCk1ICUS
CorucosLerold group
no MorLallLy beneL
Shock 8eversal" 2
days
Cdds rauos
Pyperglycemla (1.18)
Superlnfecuon (1.27)
new sepsls (2.97)
new sepuc shock
(2.78)
nL!M 2008, 338:111
A 32 year o|d woman w|th a known
pheochromocytoma |s about to undergo an
e|ecnve breast b|opsy. Wh|ch drug shou|d be
adm|n|stered pre-operanve|y to th|s panent?
1. MeLanephrlne
2. henLolamlne
3. ropranolol
4. henoxybenzamlne
3. Clonldlne
heochromocytoma
1rlad - headache, sweaung and Lachycardla
uncommon
Lplsodlc P1n - uux lncludes
CLher causes of sympaLheuc acuvlLy lnclude
AuLonomlc: Splnal ln[ury or Culllaln-8arre syndrome
SympaLhomlmeuc drugs
Cocalne, pheynlcyclldlne, ampheLamlnes
lngesuon of Lyramlne conLalnlng foods ln pauenLs
Laklng MAC lnhlblLors
heochromocytoma
ulagnosls
lasma meLanephrlne and normeLanephrlne
24 hour urlne meLanephrlnes, and caLacholamlnes
Crlucal lllness can produce false posluve levels
So can Lrlcycllc anudepressanLs
Surgery can preclplLaLe a crlsls
reop alpha blocklng agenL - phenoxybenzamlne
#-blocker conLralndlcaLed unless prlor alpha blockade
P1n LreaLmenL - phenLolamlne
2-3 mg every 3 mlnuLes
In panents w|th d|abetes |ns|p|dus the
adm|n|stranon of desmopress|on aects ur|ne
osmo|a||ty |n wh|ch of the fo||ow|ng ways?
1. urlne osmolallLy remalns unchanged ln pauenLs
wlLh cenLral ul
2. urlne osmolallLy rlses ln pauenLs wlLh cenLral ul
3. urlne osmolallLy falls ln pauenLs wlLh cenLral ul
4. urlne osmolallLy rlses ln pauenLs wlLh nephrogenlc
ul
3. urlne osmolallLy falls ln pauenLs wlLh nephrogenlc
ul
D|abetes Ins|p|dus (DI)
CenLral ul - lack of Lhe AuP - arglnlne vasopressln
anhypoplLulLarlsm (Sheehan's), anoxla, Lrauma, Lumors
lnlLrauve condluons sarcoldosls, lymphoma
lnfecuous dlseases - neurosyphllls or Luberculosls
nephrogenlc dlabeLes lnslpldus - lack of
responslveness of Lhe collecung Lubules
urugs -llLhlum, demeclocycllne, amphoLerlcln 8,
anureLrovlral drugs - Lenofovlr and lndanlvlr
LlevaLed AuP levels
D|abetes Ins|p|dus
SympLoms due Lo
Loss of free waLer - polyurla, polydlpsla, hypernaLremla,
volume conLracuon, hyperosmolallLy
Lab
Low urlne Speclc CravlLy
Plgh-normal plasma sodlum concenLrauon (> 142 meq/L)
urlne osmolallLy < plasma osmolallLy
vs. rlmary polydlpsla na < 137 meq/L
Low urlne osmolallLy (< 1/2 plasma osmolallLy)
Centra| vs. Nephrogen|c DI
uesmopressln 1 ug SC
CenLral ul - lncrease urlne osmolallLy > 30
arual CenLral ul - lncrease 10-30
nephrogenlc ul - no lncrease ln ur osmolallLy
1reaLmenL
CorrecL free waLer declL
0.6 x kg x [(na
+
measured/140) - 1]
AdmlnlsLer nS unul hypovolemla, hypoLenslon correcLed
Can admlnlsLer hypoLonlc sallne aer LhaL
CenLral ul - desmopressln 1-2 ug SC q12 hours
nephrogenlc - sLop drug cause, Lhlazlde dlureuc
Lndocr|ne Lmergenc|es - kandom ear|s
ukA glucose < 800, keLones elevaLed
lree WaLer declL 0.3 for women, elderly men
= [0.6 x kg] x [(na
+
measured/140) - 1]
1reaL hypovolemla wlLh nS
1reaL myxedema and Lhryold sLorm before labs back
SLress can preclplLaLe underlylng endocrlne condluons
Sheehan's syndrome
LLomldaLe - adrenal lnsumclency
heo - preop phenoxybenzamlne
P1n - phenLolamlne
Some anureLrovlrals - nephrogenlc ul