Endocrinology

There are many Endocrine diseases that need the urgent care in emergency setup , but we will discuss some of them;

1. Hypoglycemia.
2. Hyperglycemia.
3. Thyroid emergencies.

1- Hypoglycemia:

Definition:
The Hypoglycemia occurs when blood sugar or blood glucose concentrations fall below a level necessary to properly support the body's need for energy and stability throughout its cells.
* Blood suger < 3mmol (i.e. 56mg/dl).

Sign & Symptoms of Hypoglycemia:
Anxiety.
Palpitation.
Drowzy.
Coma.
Sweating.
Fits.

Types of Hypoglycemia:

1. Fasting Hypoglycemia.
2. Postprandial Hypoglycemia.

1. Fasting Hypoglycemia:

(1) If patient is diabetic then, increase dose of insulin can cause hypoglycemia:

Other than it, other causes or reasons are;

a) High dose.

b) Exact dose but miss the meal.

c) Meal and dose in balance but work hard than normal routine.

(2) If patient is non. Diabetic then, Decrease suger level can cause hypoglycemia:

Other than it, other causes or reasons are;

a) Exogenous Drugs, Sulphonyl urea and Antimalaric drugs.

b) Pituitary Insufficiency.

c) Liver failure (Failure of glyconeogenolysis).

d) Addison's Disease (Decreased secretion from adrenal gland).

e) Insulinoma (Tumor of insulin cell).

* Increase the secretion of insulin that cause the hypoglycemia.

f) Neoplasia (Cancer or malignancy).

* Any cancer in the body can cause hypoglycemia.

Investigations:

Blood suger level.

Labs.

Insulin level.

C-peptide level (that produce with insulin).

* Examples:

Patient no 1: Increased insulin

                     Increased C-peptide

Result: Internal insulin production (Insulinoma).

Patient no 2: Increased insulin

                     Decreased C-peptide

Result: External insulin taken by patient.

2. Postprandial Hypoglycemia: (After meal)

In case of Gastrectomy (Removed stomach).

Food travels esophagus to Jejunum.

Food Dumped or stay in Jejunum.

Food not properly absorbed (complicated mechanism), that lead to the hypoglycemia.

Management:

Oral drinks in conscious patients.

If patient is unable to drink i.e. unconscious then give following;

Inj. IV 25 % (50 %) D/W (Immediate).

Inj. IM Glucagon 10-15 min.

Infusion IV 10 % of D/W.

2. Hyperglycemia:

Definition:
Hyperglycemia is defined as an abnormally increased content of glucose in the blood.
Only in type 1 DM pH fall from 7.00 to 3.8.
It cause ketoacidosis in diabetic and plus minus hyperglycemia.
Its due to excessive ketones in the blood.

Precipitants:
There are some factors that cause ketoacidosis;
1- Infection (When infection occur, insulin demand increases).
2- Myocardial infarction (Due to stress insulin balance disturb, MI cause stressful condition which can cause diabetes.
3- Wrong doses (Insufficiency due to, if any one not taking exact dose).
4- Non. Compliance (If someone not using the medicine).

Sign & symptoms of Hyperglycemia:
Polyurea.
Polydyspea (more thirst).
Lethargy (weakness).
Hyperventilation.
Anorexia (loss of appetite).
Abdominal pain.
Confused.
Drowsy.
Comatosed (at advanced state).

Investigation:
Blood suger level.
ABGs.
Urine examination for ketones.
CBC.
Urea & Electrolytes.
* Because there, dehydration may occur.

Serum amylase.
* In acute Pancreatic condition.

ECG.
X-Ray.

Management:
Check vitals after 1 hour.
Folys catheter.
Maintain 2 IV lines.
* 14 & 16 G (big) & small.

Oxygen therapy.
Re-hydration with 0.9 % Normal saline

1 L   State
1 L   2 hours
1 L   2 hours
1 L   4 hours

Fluid Management:
Due to more K+ dilute and risk of hypoglycemia so, K+ replacement must be done.
Insulin administration; Insulin stat 6 unit of IV or 10 unit of IM.
After stabilization, insulin 2 to 4 units per hour.
Heparin (anticoagulant) for reduce the blood viscosity.

* Also treat the underlying cause of hyperglycemia.

3. Thyroid Emergencies:
Location: In Front of neck.
Function: Pituitary ___ TSH ___ Thyroid (T3 + T4).

Pituitary Gland          Thyroid Gland
Increased TSH            Decreased T3, T4     (Primary Hypothyroidism)
Decreased TSH            Decreased T3, T4     (Secondary Hypothyroidism)
Decreased TSH            Increased T3, T4     (Hypothyroidism)

Types of Thyroid Emergencies:
Myxodema Coma.
Thyrotoxic Storm.

Myxodema Coma:
Patient become drowsy due to marked low level of thyroidism (Secretion from thyroid gland) cause hypothyroidism.

Sign & Symptoms:

1. Drowsiness.
2. Coma.
3. Hypothyroidism.
4. Excessive hypothermia.
5. Bradycardia (decreased HR +/- hypertension).
6. +/ - Hypoglycemia.

Precipitants:
There are some factors that leads to stable condition to unstable condition;

1. Infection.
2. Non. Compliance.
3. Myocardial Infarction.
4. Neurological Stroke.
5. Trauma.

On Examination:

1. Pulse (Decreased).
2. Blood Pressure (Increased).
3. Temperature (Decreased).
4. Respiratory rate (Increased).
5. CVP Volume (Decreased).
6. Urine output.
7. Heart Failure Signs present.
8. Neck Examination.
9. + / - Sign of Hypothyroidism.

Management:
Intensive care unit Care
T3, T4, TSH, FBC, Blood cultures and U &E test to be perform must.
Secure two IV lines (14 & 16 G).
ABGs ___ PaO2
T3 IV 5-20 microgram per 24 hours.
IV Fluids (Normal Saline).
* In heart failure patient avoid fluids.

Warm Blanket + Gradual Rewarming.
33 - 35C ___ 37C ___ Hyperthermia.
Antibiotics.
If patient stable, Oral Thyroxine T4 (50 mg).
Hydrocortisone (100 mg TDS ).

2. Thyrotoxic Storm:

Signs & Symptoms:

1. Anxious.
2. Agitated.
3. Febrile (Hyperthermia).
4. Hyper-reflexia.
5. Palpitation.
6. Confused.
7. Coma.

Precipitation:

1. Fever
2. Infections.
3. Surgery of thyroid gland on unprepared patient i.e. anti-thyroid drugs not given before surgery).
4. Radio-Iodine therapy (Treatment for thyroid but have risk of crisis).

Management:
Maintain IV line (0.9% Normal saline).
Sedative drugs (Diazepam / Dormicum).
IV Beta blockers (Propanalol +/ - Digoxin).
Anti-thyroid drugs (Carbimazole).
Steroids (Hydrocortisone 100 mg TDS ).
Antibiotics.