Endocrine

Question 1

Diabetic ketoacidosis

Answer 1

• more common in younger<65 & T1DM
• Rapid onset <24 hours
• Hyperglycemia (Serum glucose 300-800)
• Anion gap acidosis (pH<7.3, anion gap >20 mEq/L) - serum bicarb is usually severely low
• Ketonemia from lipolysis
• Urine losses >5L
• Hyperglycemic s/s: polyuria, polydipsia, polyphagia, osmotic diuresis, profound dehydration, tachycardia, hypotension
• DKA specific s/s: N/V, abdominal pain, compensatory Kussmaul respiratory to breathe off the excess acid

Question 2

Serum osmolality

Answer 2

275-295 mOsm/kg

Question 3

Urine Osmolality

Answer 3

500-800 mOsm/kg

Question 4

Hyperosmolar Hyperglycemic State (HHS)

Answer 4

• Enough endogenous insulin, minimal or no ketoacid accumulation
• Slow onset - several days
• Hyper mortalilty
  -Common in older >65 and T2DM
• Severely elevated blood glucose >1000 mg/dL
• Hyperosmolality >320 mOsm/kg
• low to normal pH>7.3
• Urine loss >9 L/day
• HHS specific s/s: neuro change, HA, lethargic, obtundation, coma

Question 5

DKA/HHS Treatment

Answer 5

• Replace lost fluid & electrolytes (isotonic crystalloids - NS/LR)
• Correct blood sugar
• Check ABGs, BUN/Cr, electrolytes q4h
• BG check q1h
• If K<3.3, replace before IV insulin to void hypokalemia!!
• Start insulin infusion at 0.1 units/kg/hr and titrate per protocol
• Change IVF to D51/2Ns once BG <250mg/dL and serum sodium normalizes
• Tx to SQ insulin once BG <200
• Continue IV insulin for 2-4 hours after to avoid hyperglycemia recurrence
• Resume PO diet
• Replace Na, Ca, Phos

Question 6

Syndrome of Inappropriate Antidiuretic Hormone (SIADH)

Answer 6

• Impairment of negative feedback mechanism and causes inability to suppress ADH secretion so the body holds on to too much water and can’t excrete in the urine
• Causes: CNS disorder (stroke, hemorrhage, infection, trauma, psychosis), tumors from small cell carcinoma in the lung can cause an ectopic production of ADH, pulmonary disorders (i.e., pneumonia), pituitary surgery
• Dx: Low sodium <130 (dilutional hyponatremia), low serum osmolality <275, high urine osmolality >100, high urine sodium >40 (normal 20), urine output - low and concentrated <0.5 ml/kg/hr
• Tx: fluid restriction <1L/day, Iv hypertonic saline, correct sodium level slowly to prevent osmotic demyelination syndrome

Question 7

Antidiuretic hormone (ADH)

Answer 7

• Vasopressin formed in the hypothalamus and released from the posterior pituitary gland in response to increased serum sodium levels
• ADH stimulates kidneys to reabsorb water, concentrate urine, correct the serum osmolality, negative feedback mechanism

Question 8

Diabetes insipidus

Answer 8

• Insufficient secretion of ADH
• Cause: Neurogenic/central DI: insufficient ADH secretion, nephrogenic DI - kidneys don’t respond to ADH, Phenytoin (Dilantin)
• Dx: Polyuria r/t lack of ADH (5-15L/day), dilute urine, low urine osmolality <200 mOsm/kg, low specific gravity <1.005, high serum sodium >145, high serum osmolality >295, polydipsia
• Tx: replace ongoing fluid losses (replace 1/2 of free water over 1st 24hours, then slowly over next 2-3 days to prevent cerebral edema), replace ADH - Desmopressin (DDAVP), sodium-restricted diet closely monitor UO and serum Na and notify if UO>200 ml/hr x2.

Question 9

Urine specific gravity

Answer 9

1.010-1.020

Question 10

Adrenal Insufficiency (Addison’s Disease)

Answer 10

• Rare disorder where autoimmune destruction of the adrenal glands results in insufficient production of hormones that the body needs (aldosterone and cortisol)
• S/S: fatigue, weight loss, syncope, depression, hyperpigmentation of the skin
• Dx: hyponatremia from sodium loss and water retention, hyperkalemia d/t inability to excrete potassium in the urine, hypoglycemia

Question 11

Aldosterone

Answer 11

• Stimulates kidneys to hold on to sodium and water in response to low blood pressure
• Regulates potassium levels
• Promotes the excretion of potassium in the urine

Question 12

Cortisol

Answer 12

• Stimulates the production of glucose in the liver
• Breakdown fat
• Keeps immune response and inflammation in check

Question 13

Adrenal crisis

Answer 13

• Peripheral vascular collapse and vasodilatory shock, - A life-threatening emergency
• Check electrolytes, glucose, cortisol, and ACTH
• Rapid infusion of 2-3L of NS or D5NS to support BP and hypoglycemia
• Hydrocortisone 100mg IV bolus, followed by 50mg IV q6h until VS stabilize

Question 14

Hyperthyroidism

Answer 14

• Excess production of thyroid hormones
• Causes: Grave’s disease (most common) - an autoimmune disorder
• S/S: a diffuse palpable goiter, sinus tachycardia, arrhythmias, afib, HTN, tremors, palpitations, fatigue, weight loss despite increased appetite, excess perspiration and heat intolerance, exophthalmos, periorbital edema
• Dx: TSH low, T3/T4 high

Question 15

Thyroid storm

Answer 15

• Life-threatening manifestation of hyperthyroidism
• Severe hypermetabolism
• Tachycardia >140, arrhythmia progressing to CHF (CV collapse and hypotension leading to cardiogenic shock), hyperpyrexia (hyperthermia) w/ temp >104, altered mentation
• Agitated, anxious, delirious, psychosis, stupor, coma
• Tx: Beta-blockers (propanolol, esmolol) to reduce adrenergic tone and reduce serum T3 levels; Propylthiouracil (PTU) and iodine to stop the production and block the release of thyroid hormones; glucocorticoids (IV hydrocortisone) to suppress autoimmune process and reduce T3
• Supportive: reverse hyperthermia with cooling measures and Tylenol, IVF to correct fluid losses and BP, monitor hemodynamic w/ CHF, in severe cases possible ventilation

Question 16

Hypothyroidism

Answer 16

• Lack of production of thyroid hormones especially T4
• Causes: Hashimoto’s Disease (an autoimmune disorder that destroys thyroid tissue), iodine deficiency, amiodarone (high contents of iodine contributes to hypothyroidism)
• S/S: decreased mental status, fatigue, cold intolerance, bradycardia, hypotension, ascites, edema

Question 17

Myxedema Coma

Answer 17

• Severe form of untreated hypothyroidism
• S/S: altered mental status, hypothermia, hypotension, bradycardia, hyponatremia, hypoglycemia, hypoventilation
• Tx: replace thyroxine T4 (Levothyroxine), T3

-Supportive: mechanical ventilation, fluids, pressors, passive rewarming, IV dextrose, close monitoring for arrhythmias

Question 18

Metabolic syndrome

Answer 18

• High risk for developing CV disease & stroke
• Dyslipidemia (TG>150 mg/dL, low HDL <40-50)
• HTN (SBP >130, DBP >85)
• Hyperglycemia (FBG >100, dx T2DM)
• Abdominal obesity (waistline >40 male >35 female)