This document summarizes several endocrine emergencies including hypoglycemia, diabetic ketoacidosis, hyperosmolar hyperglycemic nonketotic syndrome, adrenal crisis, pheochromocytoma, thyroid storm, and myxoedema coma. For each condition, it describes the causes, signs and symptoms, investigations, and management principles. The goal of management is resuscitation, treatment of the underlying cause, and stabilization of vital signs and metabolic derangements.

1. Endocrine emergencies
By Dr. Mohammed Al Ameen

2. Hypoglycemia
• <60mg/dl, <4mmol/L
• Protection against hypoglycemia is normally
provided by cessation of insulin release and
mobilization of counter-regulatory hormones

3. Causes
• Overdose of insulin or oral hypoglycaemic
agents
• Alcohol-induced hypoglycaemia
• Addison’s disease
• Insulinomas.
• Liver failure.
• Extra-pancreatic tumors.
• Pituitary insufficiency.

4. Signs and symptoms
• Signs and symptoms of hypoglycemia are caused by
excessive secretion of epinephrine and CNS dysfunction
• sweating, nervousness, tremor, tachycardia, hunger, and
neurologic symptoms ranging from bizarre behavior and
confusion to seizures and coma.
• hypoglycemia unawareness.
• Somogyi phenomenon

5. Investigations
• Blood glucose
• LFT
• Electrolytes
• ECG
• C-peptide

6. Management
• C A B
• 50% dextrose in water (D50W) is administered
intravenously
• Alcohol-thiamine
• <8yrs-25% (D25W) or even 10% (D10W) dextrose
• Glucagon 1mg
• Discharge- cause for the episode and fully recovered

7. Diabetic Ketoacidosis
• An acute metabolic complication of diabetes
characterized by
• hyperglycemia
• hyperketonemia
• metabolic acidosis

8. Causes
• Infection
• Infraction
• Insufficient insulin

10. Symptoms and signs
• Signs of dehydration
• GI symptoms
• Kussmaul respiration, fruity breath
• Neurological symptoms :altered level of conciousness
,confusion, coma and death – if not treated timely

11. Investigations
• Blood glucose
• ABG
• Serum ketones
• Infective screen
• Blood tests— urea and electrolytes, FBC, and
bicarbonate
• ECG and cardiac monitoring

12. Treatment
• A B C
• Fluid management -resuscitation
-replacement
• Insuline 0.1 unit/kg/hour, ketones do not fall by at least 0.5
mmol/L/hour the infusion rate should be increased by 1
unit/hour
• Change IV solution to D5W when glucose concentration is
≤300 mg/dL
• Potassium replacement
Over 5.5mmol/l Nil
3.5–5.5mmol/l 20 mmol/L
Below 3.5mmol/l 40–60 mmol/L (HDU support
required)

13. • Sodium, Phosphorus & magnesium
• Bicarbonates
• Monitoring: Fluid balance should be monitored,
aiming for a urine output > 0.5 ml/kg/hr. Blood
ketones and capillary glucose should be measured
hourly . ABG every 2 hrs.

14. Hyperosmolar hyperglycemic
nonketotic syndrome
• Pathophysiology: there is enough circulating insulin
to prevent ketogenesis , and therefore acidosis
• Clinical features similar to DKA
• Investigation: blood glucose >30mmol/l, serum
osmolality
• Management: similar to DKA

15. Acute adrenocortical
insufficiency

17. • Precipitants of an adrenal crisis include:
Infection.
Trauma.
Myocardial infarction.
Stroke.
Asthma.
Hypothermia.
Alcohol.
• Exogenous steroid withdrawal/reduction.

18. Clinical features
• Onset is usually insidious with features including
weight loss, lethargy, weakness, vague abdominal
pain, nausea
• Adrenal crisis the patient can be profoundly shocked
(tachycardic, hypotensive, vasoconstricted,oligouric)
and hypoglycaemic

19. Investigation
Serum cortisol and plasma ACTH
RFT:Hyponatraemia.
Hyperkalaemia.
Elevated urea and creatinine.
Blood glucose: Hypoglycaemia.
ABG: Metabolic acidosis.
To identify the precipitant : ECG, CT, CBC, blood culture,
CXR, urine routine .

20. Treatment
• A B C
• Hydrocortisone 100 mg IV should be given as soon as
an adrenal crisis is suspected.
• Fluid resuscitation
• Patients should be monitored for hypoglycemia.
• Treat the precipitant

21. Phaeochromocytoma
• functional tumors that arise from
chromaffin cells in the adrenal medulla
• Catecholamines α –receptors and β -receptors

22. Clinical features
• Hypertension.
• Palpitations.
• Sweating.
• Pallor.
• Headache.
• Anxiety.
• Pulmonary oedema.
• Nausea and vomiting.
• Altered level of consciousness (hypertensive
encephalopathy)

23. Diagnosis
• 24-hour urinary free catecholamines level
• CT/MRI

24. Treatment
• Phenoxybenzamine ( α -blocker) is the drug of
choice.
• Propranolol

25. Thyroid storm

26. Precipitating factors of a thyroid
storm
• Infection
• Non-thyroidal trauma or surgery
• Parturition, pre-eclampsia
• Major acute medical conditions,
e.g.myocardial infarction, DKA,
HONK,hypoglycaemia.

27. • Radioiodine or high-doses of iodine-containing
compounds, e.g. contrast media, amiodarone.
• Discontinuation of anti-thyroid medication.
• Thyroid hormone overdose
• Thyroid injury (infarction of an adenoma, neck
trauma)

28. Clinical Feature
• Cardiovascular — severe tachycardia, atrial
fibrillation, congestive heart failure, hypertension.
• Neurological — agitation, confusion, delirium, coma.
• Gastrointestinal dysfunction — vomiting, diarrhoea,
acute abdomen.
• Fever.

29. Investigation
• Bloods — renal function, glucose, calcium, FBC,
thyroid function tests.
• Infective screen
• ECG

30. Treatment
• Inhibition of thyroid hormone synthesis and release
- propylthiouracil and carbimazole
- Iodide
• Inhibition of peripheral effects of thyroid hormone
-propranolol 80 mg PO
- hydrocortisone 100 mg IV or
dexamethasone 4 mg PO
• Treat underlying cause
• Supportive management

31. Myxoedema coma
• Myxoedema coma is a rare condition typically found
in elderly patients with undiagnosed or undertreated
hypothyroidism.
• Precipitants : infections or infractions
• Clinical features :- Altered mental state ranging from
poor cognitive function to coma.
-Hypothermia or the absence of fever
despite severe infection
• Management – Thyroid profile, Thyroid hormones,
Hydrocortisone, Rx precipitant

32. Thank you