Diabetes and OtherEndocrine Emergencies

Dr Britney FrazierMAJ (P), MC, US Army

Madigan Healthcare System

Tacoma WA

Disclosure Information

� I have no relevant financial relationships with the manufacturer(s) of any commercial product(s) and/or provider(s) of commercial services discussed in this CME activity.

� I do not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation.

� The views expressed are those of the author(s) and do not reflect the official policy of the Department of the Army, the Department of Defense or the U.S. Government.

Learning Objectives

� Understand the management of non-DKA diabetes mellitus emergencies

� Recognize insulin pump failure and formulate management plan

� Demonstrate understanding of hypoglycemia

� Recognize & treat adrenal insufficiency

� Understand thyrotoxicosis

Case One

� You receive a phone call from Sara’s mom about her insulin dosing. Sara is a 10 yr old with type 1 DM. She receives Lantus every morning and Novolog prior to meals. Sara awoke this morning feeling nauseated & has a fever of 101F. Her AM d-stick was 83. Mom is calling to determine what she should do today in terms of managing Sara’s diabetes.

Case One: Discussion Points

� Patient is nauseated & not hungry so what should she do?

� What are “sick day” guidelines that you recommend?

� What insulin dosing would you recommend?

Patient is nauseated, not hungry & has lowish d-stick so what should she do?

What are “sick day” guidelines that you recommend?

What insulin dosing would you recommend?

Case Two

� Sam is a 16 yr old on an insulin pump for the past two years. He awoke this morning & vomited. His AM d-stick was 382. Sam ate bfast and dosed his insulin as usual. An hour later, dad calls you as he checked Sam’s d-stick prior to him boarding the bus and it was 410. Dad asks you what to do now?

Case Two: Discussion Points

� What do you think caused Sam to have vomiting & hyperglycemia this morning?

� What should Sam do now in terms of insulin dosing?

� What other recommendations do you make?

What do you think caused Sam to have vomiting & hyperglycemia?

What should Sam do now in terms of insulin dosing?

What other recommendations do you make?

Case Two continued…

� Sam’s dad calls back later and says that Sam is having too many problems with his insulin pump due to his poor compliance. They would like to discontinue Sam’s pump. Dad needs to know how to dose Sam’s insulin via injection as they have been relying on the pump for dosing. What do you tell Sam’s dad?

Case Two: Discussion Points

� What are Sam’s insulin doses via injection if he discontinues his pump?

What are Sam’s insulin doses via injection if he discontinues his pump?

Case Three

� Emily is a 17 yr old female who presents for follow-up of her type 1 DM. Her A1C is 7.7 She is on Levemir & Humalog. She has been having frequent hypoglycemia recently. Emily also feels weak and fatigued & has occasional abdominal pain. What is your differential diagnosis?

Case Three: Discussion Points

� What is your DDx for Emily in light of her hypoglycemia, fatigue/weakness, & abdominal pain?

� What else would be important for her history & physical?

� Which labs/studies would you order?

What is your DDx for Emily in light of her hypoglycemia, fatigue, & abdominal pain?

What else would be important for Emily’s history & physical?

Which labs/studies would you order?

Case Three continued…

� Two mornings later you receive a page from the ER, Emily presented with hypoglycemia, confusion, & emesis. Her d-stick in the ER was 26. She is hypotensive and her labs reveal hyponatremia, hyperkalemia & hypoglycemia. Now what is your diagnosis?

Case Three: Discussion Points

� What is your diagnosis for Emily?

� What is the appropriate treatment for this emergency?

What is your diagnosis for Emily?

What is the appropriate treatment for adrenal crisis?

Case Four

� Mary is a 14 yr old who presents for follow-up on her type 1 DM. Mom is concerned about Mary’s weight loss & fatigue since returning from camp this summer. Mary’s A1C is 12.2 Mary reports feeling “fine” although she does note lack of menses for “months”. On exam, she has lost 6kg since her last appt. What are you concerned about?

Case Four: Discussion Points

� What diagnosis are you most concerned about in light of Mary’s poorly controlled diabetes & weight loss?

What diagnosis are you most concerned about?

Case Five

� You are rounding in the newborn nursery. Baby Jitter is a term infant female who is now DOL#4. She has had recurrent hypoglycemia since birth. You decide to obtain “critical labs” with her next episode of hypoglycemia.

Case Five: Discussion Points

� What are the “critical labs” for hypoglycemia?

� What is your DDx for neonatal hypoglycemia?

What are the “critical labs” for hypoglycemia?

What is your DDx for hypoglycemia?

Case Five continued…

� Baby Jitter’s TFTs return that same afternoon but you are still awaiting the remaining labs. Both her TSH & FT4 are low. Now what?

Case Five: Discussion Points

� Her labs are consistent with central hypothyroidism. Do you treat her now? Or wait? Why?

� She was born in WA state, why did her state newborn metabolic screen not detect her hypothyroidism?

Her labs are consistent with central hypothyroidism. Do you treat her now or wait?

She was born in WA state, why did her state newborn metabolic screen NOT detect her hypothyroidism?

Case Five continued…

� Infant Jitter’s labs all return. When her serum glucose was 22, she had the following critical labs:

◦ Cortisol- low

◦ GH- low

◦ Urine ketones- moderate

◦ Insulin- low

� And as noted, she also had low TSH & FT4. What is her diagnosis?

What is the cause of Baby Jitter’s hypoglycemia?

Case Six

� Baby Bean is a term three day old infant with fever, tachycardia, hypertension & irritability. Mom was taking levothyroxine, but had normal TFTsduring her pregnancy. On exam, infant is jittery & thin. What endocrine disease might be causing this?

Case Six: Discussion Points

� What endo disease may be causing this infant’s tachycardia, fever, HTN and irritability?

� What is the appropriate evaluation & treatment?

What endo disease may be causing this infant’s tachycardia, fever, HTN and irritability?

What is the appropriate evaluation & treatment for neonatal Graves?

Case Six continued…

� If Baby Bean had been asymptomatic, but mom had known history of Graves, what is the appropriate evaluation?

Case Seven

� You receive a call about an abnormal congenital adrenal hyperplasia screen for a now 5 day old infant male. What should you do next?

Case Seven: Discussion Points

� What should you do regarding the abnormal CAH screen?

� What is the most common cause of CAH?

� What is the appropriate treatment plan?

What should you do regarding the abnormal CAH screen?

What is the most common cause of CAH?

What is the appropriate treatment plan for classic 21-OH deficiency?

Summary

� In diabetics, good education & prevention of DKA is key

� Recognition and appropriate treatment of adrenal insufficiency is life-saving

� In infants, keep a high-index of suspicion for endocrine/metabolic disorders

Any questions?