Endocrine Emergencies: MCQ/SBA

Syllabus

Domain:•2.2: Tests of endocrine function (DM, Thyroid, Adrenal)•3.1: Manage critical illness-induced hyperglycaemia, DM, hypoadrenalism, hypo/hyperthyroidism, sepsis-induced relative adrenal insufficiency, endocrine emergencies•3.2: Identify the implications of chronic illness in DM, thyroid disease, adrenal and pituitary disorders•4.1: Understand the pharmacology of anti-diabetic drugs and corticosteroids•6: Manage perioperatively DM and hypoadrenalism, manage patients with surgery to thyroid, adrenals, pituitary

1.In hyperosmolar hyperglycaemic state:

• The osmolality is usually >320mOsmol/kg

• Hyperglycaemia is less marked than in DKA

• Has a higher mortality than DKA

• Thrombotic complications are rare

• Onset maybe over several days

• There is never any ketosis

2. In thyrotoxicosis:

• Ophthalmopathy only occurs in Graves’ disease• Increased cardiac output is due to increased

contractility• AF is more common in younger patients• Commonest cause is toxic multinodular goitre• Patients always lose weight• In primary hyperthyroidism the TSH is high• Beta-blockers should only be started once specific

anti-thyroid drugs have been commenced

3. Phaeochromocytomas

• Arise from the adrenals only• Secrete mainly noradrenaline• Are associated with MEN type 2• In symptom control, beta-blockade should start

before alpha-blockade• Onset of postural hypotension is a marker of

optimum pre-operative control• A crisis may be precipitated by induction of

anaesthesia• Ligation of the tumour’s venous supply can be

associated with profound hypotension

4. In Diabetic ketoacidosis:

• It only occurs in Type I DM• Requires ketonaemia>4mmol/l• The specific ketone tested is 3-beta-

hydroxybutyrate• The mortality in the UK is about 8%• The most common cause of mortality is cerebral

oedema

5. In the management of DKA:

• Start replacing potassium when <4• Aim for decrease in ketones by 1mmol/l/hr• 10% dextrose should be the fluid of choice once

blood glucose<14mmol/l• I.v. insulin infusions should be stopped once

ketones<0.3• The Joint British Diabetic Society Guidelines

recommend the use of colloids for fluid replacement

6. A 40 year old lady presents to ED at 21.00 with nausea, lethargy and weakness. Her BP

drops from 110 systolic to 85 on standing. What is the best initial management?

1. Give iv fluids, await morning to do short synacthin test

2. Give iv hydrocortisone 50mg, maintenance fluids, refer to Endocrinology in the morning

3. Take blood sample for cortisol then give i.m 100mg hydrocortisone, titrate iv fluids thereafter

4. Perform short synacthin test and await results before giving steroids

7. A 58 year old lady is brought to ED with reduced GCS. She is unrousable with GCS 7 (E1V2M4). HR 42, BP 92/40, Temp. 35.6. She has coarse, waxy skin and weak peripheral

pulses. TSH is 35. The best initial management is:

1. Send bloods including cortisol, give stat 100mg im hydrocortisone, intubate and ventilate, start T3

2. Fluid resuscitate, actively re-warm, intubate if still low GCS, start thyroxine via NG

3. Passive re-warm, start vasopressors, intubate and ventilate, stat 100mg i.m. hydrocortisone

4. Intubate to protect the airway, start vasopressors then investigate further with T3/T4

8. A 78 year old lady with type II DM presents ot ED having been unwell for several days with malaise,

nausea and dysuria. She is now drowsy and confused. Bloods show Na 154, K 4.9, Ur 10.5, Cr 130, Glu 58, pH

7.35 Ketones 0.3. What is the best management strategy:1. Start FRII at 0.1units/kg/hr, give 0.45% saline with

potassium, start antibiotics, send to ward2. Give her normal stat dose of once a day sc insulin,

bolus fluids titrated to BP, send off urine and blood cultures

3. Give iv 0.9% saline, upto 3-6 litres in 12 hours, start empirical antibiotics, give dalteparin prohylaxis, admit to HDU

4. Fluid resuscitate with Hartmanns, start antibiotics, give insulin at 0.05units/kg/hr

9. A 22 year old, weight approx. 60kg, presents with polyuria, polydipsia and now vomiting. ABG: pH 6.98 BE-18 Lac 1.9, Glu

28, ketones 7. What is the best management?1. Start FRII at 6ml/hr, then give stat 1litre of 0.9%

saline, stat dose of lantus of 5units/kg2. Start VRII according to blood sugar, fluid

resuscitate to BP, monitor ketones every 4 hours3. Give 1 litre 0.9% saline, then start FRII at 6ml/hr,

continue fluid replacement, monitor glucose and ketones hourly

4. Give 1 litre of 0.9% saline, start VRII, monitor blood glucose and ketones hourly

10. A 25 year old has an emergency c/section for her first baby due to obstructed labour. She has a 2.5litre PPH from uterine

atony. Over the next 48 hours she c/o headache, lethargy and is unable to breast-

feed. Her BP is 90 systolic. What is the cause?

1. Cerebral vein thrombosis2. Secondary PPH3. Sepsis4. Sheehan’s syndrome

1.In hyperosmolar hyperglycaemic state:

• The osmolality is usually >320mOsmol/kg T

• Hyperglycaemia is less marked than in DKA F

• Has a higher mortality than DKA T (15-20%)

• Thrombotic complications are rare F

• Onset maybe over several days T

• There is never any ketosis F

2. In thyrotoxicosis:

• Ophthalmopathy only occurs in Graves’ diseaseT

• Increased cardiac output is due to increased contractility T• AF is more common in younger patients F• Commonest cause is toxic multinodular goitre F• Patients always lose weight F• In primary hyperthyroidism the TSH is high F• Beta-blockers should only be started once specific

anti-thyroid drugs have been commenced F

3. Phaeochromocytomas

• Arise from the adrenals only F• Secrete mainly noradrenaline T• Are associated with MEN type 2 T• In symptom control, beta-blockade should start

before alpha-blockade F• Onset of postural hypotension is a marker of

optimum pre-operative control T• A crisis may be precipitated by induction of

anaesthesia T• Ligation of the tumour’s venous supply can be

associated with profound hypotension T

4. In Diabetic ketoacidosis:

• It only occurs in Type I DM F• Requires ketonaemia>4mmol/l F (>3)• The specific ketone tested is 3-beta-

hydroxybutyrate T• The mortality in the UK is about 8% F (<1%)• The most common cause of mortality is cerebral

oedema T

5. In the management of DKA:

• Start replacing potassium when <4 F (<5.5)• Aim for decrease in ketones by 1mmol/l/hr

F(0.5)• 10% dextrose should be the fluid of choice once

blood glucose<14mmol/l T• I.v. insulin infusions should be stopped once

ketones<0.3 F (<0.6)• The Joint British Diabetic Society Guidelines

recommend the use of colloids for fluid replacement F

6. A 40 year old lady presents to ED at 21.00 with nausea, lethargy and weakness. Her BP

drops from 110 systolic to 85 on standing. What is the best initial management?

1. Give iv fluids, await morning to do short synacthin test

2. Give iv hydrocortisone 50mg, maintenance fluids, refer to Endocrinology in the morning

3. Take blood sample for cortisol then give i.m 100mg hydrocortisone, titrate iv fluids thereafter

4. Perform short synacthin test and await results before giving steroids

7. A 58 year old lady is brought to ED with reduced GCS. She is unrousable with GCS 7

(E1V2M4). HR 42, BP 92/40, Temp. 35.6. She has coarse, waxy skin and weak peripheral pulses.

TSH is 35. The best initial management is:

1. Send bloods including cortisol, give stat 100mg im hydrocortisone, intubate and ventilate, start T3

2. Fluid resuscitate, actively re-warm, intubate if still low GCS, give thyroxine via NG

3. Passive re-warm, start vasopressors, intubate and ventilate, stat 100mg i.m. hydrocortisone

4. Intubate to protect the airway, start vasopressors then investigate further with T3/T4

8. A 78 year old lady with type II DM presents ot ED having been unwell for several days with malaise,

nausea and dysuria. She is now drowsy and confused. Bloods show Na 154, K 4.9, Ur 10.5, Cr 130, Glu 58, pH

7.35 Ketones 0.3. What is the best management strategy:1. Start FRII at 0.1units/kg/hr, give 0.45% saline with

potassium, start antibiotics, send to ward2. Give her normal stat dose of once a day sc insulin,

bolus fluids titrated to BP, send off urine and blood cultures

3. Give iv 0.9% saline, upto 3-6 litres in 12 hours, start empirical antibiotics, give dalteparin prohylaxis, admit to HDU

4. Fluid resuscitate with Hartmanns, start antibiotics, give insulin at 0.05units/kg/hr

9. A 22 year old, weight approx. 60kg, presents with polyuria, polydipsia and now vomiting. ABG: pH 6.98 BE-18 Lac 1.9, Glu

28, ketones 7. What is the best management?1. Start FRII at 6ml/hr, then give stat 1litre of 0.9%

saline, stat dose of lantus of 5units/kg2. Start VRII according to blood sugar, fluid

resuscitate to BP, monitor ketones every 4 hours3. Give 1 litre 0.9% saline, then start FRII at 6ml/hr,

continue fluid replacement, monitor glucose and ketones hourly

4. Give 1 litre of 0.9% saline, start VRII, monitor blood glucose and ketones hourly

10. A 25 year old has an emergency c/section for her first baby due to obstructed labour. She has a 2.5litre PPH from uterine

atony. Over the next 48 hours she c/o headache, lethargy and is unable to breast-

feed. Her BP is 90 systolic. What is the cause?

1. Cerebral vein thrombosis2. Secondary PPH3. Sepsis4. Sheehan’s syndrome

Useful Docs

• http://www.diabetologists-abcd.org.uk/JBDS/JBDS.htm• DKA• HHS• Periop DM Mx

• http://www.addisons.org.uk/• Periop Addison’s Mx