Endocrine Emergencies

DKA - Sugar Storm Saga

Diabetic Ketoacidosis: life-threatening. Pathophysiology: ↓Insulin, ↑counter-regulatory hormones → hyperglycemia, ketogenesis, acidosis. Clinical Features:

• Kussmaul breathing (deep, rapid)
• Dehydration (tachycardia, ↓turgor)
• Abdominal pain, vomiting
• Altered sensorium, fruity breath 📌 Dehydration, Ketones/Kussmaul, Acidosis/Abdominal pain. Diagnostic Criteria:
• Blood glucose >200 mg/dL
• Ketonemia (β-hydroxybutyrate ≥3 mmol/L) / Ketonuria (≥2+)
• Acidosis: Venous pH <7.3 or HCO3 <15 mEq/L Management:
• Fluids: Isotonic saline (0.9% NaCl) 10-20 mL/kg bolus.
• Insulin: IV 0.05-0.1 U/kg/hr (after initial fluids).
• Potassium: Add to IV fluids (once U.O. & K+ <5.5 mEq/L). Monitoring: Hourly glucose, neuro status. 2-4 hrly electrolytes, VBG.

⭐ Cerebral edema: critical DKA complication. Signs: headache, ↓LOC, bradycardia, HTN. Manage with mannitol (0.5-1 g/kg IV), hypertonic saline, fluid restriction.

Hypoglycemia - Low Sugar Lowdown

• Definition: Glucose: Neonates <45 mg/dL; Infants/Children <50-60 mg/dL.
• Etiology:
  • Neonatal: IDM, prematurity, sepsis.
  • Childhood: Hyperinsulinism, ketotic hypoglycemia, GH/cortisol↓, IEMs, ingestions.
• Clinical:
  • Neuroglycopenic: Seizures, lethargy, coma.
  • Autonomic: Sweating, tremors, tachycardia.
• Whipple's Triad: Symptoms + Low glucose + Relief with glucose.
• Management:
  • Oral glucose (if conscious).
  • IV D10W 2 ml/kg bolus; then infusion.
  • Glucagon IM/SC (0.03-0.1 mg/kg, max 1mg) if no IV.
• Labs: Critical samples (glucose, insulin, C-peptide, GH, cortisol, ketones, lactate) before glucose.

⭐ Key: Collect critical samples (glucose, insulin, C-peptide, etc.) before giving glucose to find cause.

Adrenal Crisis - Adrenal Alarm!

• Pathophysiology: Acute deficiency of cortisol +/- aldosterone.
• Etiology: Congenital Adrenal Hyperplasia (CAH - esp. salt-wasting), Addison's disease, abrupt steroid withdrawal, pituitary failure, stress in known adrenal insufficiency.
• Clinical Features: Shock (hypotension, tachycardia unresponsive to fluids/pressors), vomiting, abdominal pain, weakness, hypoglycemia, hyponatremia (↓Na), hyperkalemia (↑K). Hyperpigmentation (chronic).
• Diagnosis: Clinical suspicion, low cortisol, high ACTH (primary), electrolyte imbalance. ACTH stimulation test (not in emergency).
• Management: ABCs, IV Hydrocortisone (stress dose: 50-100 $mg/m^2$ or age-based), IV fluids (NS or D5NS for shock & hypoglycemia), correct electrolytes, treat underlying cause.

⭐ Typical Stress Dose of Hydrocortisone (IV/IM):

• Neonates: 25 mg
• Infants (1 month - 2 years): 25-50 mg
• Children (2-12 years): 50-100 mg
• Adolescents (>12 years): 100-150 mg
• Alternative: 50-100 $mg/m^2$ initially, then divided q6h.

Other Critical Conditions - Hormone Havoc

• Thyroid Storm:
  • Precipitants: Infection, surgery, trauma (Graves').
  • Features: Hyperthermia, tachycardia (out of proportion to fever), CNS agitation/coma, GI upset. Burch-Wartofsky score.
  • Rx: PTU/Methimazole, Propranolol, Iodine solution (Lugol's/SSKI after antithyroid drugs), Hydrocortisone.
• Diabetes Insipidus (DI):
  • Types: Central (↓ADH) vs. Nephrogenic (renal ADH resistance).
  • Clinical: Polyuria, polydipsia, ↑Na+, dehydration.
  • Dx: ↑Serum Osm, ↓Urine Osm (<300 mOsm/kg), Water deprivation test.
  • Rx: Central: DDAVP. Nephrogenic: Thiazides, Indomethacin.
• Syndrome of Inappropriate ADH (SIADH):
  • Etiology: CNS disorders, lung disease, drugs.
  • Clinical: Euvolemic/hypervolemic ↓Na+, concentrated urine.
  • Dx: ↓Serum Osm, ↑Urine Osm (>100 mOsm/kg), ↑Urine Na+ (>40 mEq/L). Normal renal/adrenal/thyroid function.
  • Rx: Fluid restriction. Severe symptomatic ↓Na+: 3% saline. Demeclocycline, vasopressin receptor antagonists.

⭐ In DI, urine osmolality remains low (<300 mOsm/kg) after water deprivation; in psychogenic polydipsia, it increases (>600 mOsm/kg).

High‑Yield Points - ⚡ Biggest Takeaways

• DKA: IV fluids, insulin, K+ monitoring; slow correction prevents cerebral edema.
• Hypoglycemia: IV dextrose (D10W/D25W); glucagon if no IV access.
• Adrenal Crisis: Hypotension, hyponatremia, hyperkalemia; give IV hydrocortisone, fluids.
• CAH Salt-Wasting: Neonatal hyponatremia, hyperkalemia; give hydrocortisone, fludrocortisone.
• Thyroid Storm: Antithyroid drugs, β-blockers, iodine, steroids.
• SIADH: Euvolemic hyponatremia; treat with fluid restriction.
• DI (Central): Hypernatremia, polyuria; treat with desmopressin.