Endocrine and Electrolyte Emergencies

Thyrotoxicosis refers to the classic physiologic manifestations of excess thyroid hormones and is not synonymous with hyperthyroidism, which is caused by sustained overproduction and release of T3 and/or T4. Graves’ disease is the most common cause of primary hyperthyroidism, followed by toxic multinodular goiter and toxic adenoma. Subacute thyroiditis is an example of thyrotoxicosis without hyperthyroidism, and a pituitary adenoma, which secretes thyroid-stimulating hormone (TSH) is an example of secondary hyperthyroidism. Clinical features of thyrotoxicosis are mostly due to an increase in the metabolic rate and overactivity of the sympathetic nervous system (i.e., an increase in the β-adrenergic “tone”). Thyrotoxicosis is diagnosed by measuring the levels of TSH produced by the anterior pituitary gland and unbound T4 and T3. Depending on the etiology and clinical presentation, it may be treated pharmacologically, surgically, or with radioiodine.

Hypothyroidism is a condition characterized by a deficiency of thyroid hormones. Iodine deficiency is the most common cause worldwide, but Hashimoto's disease (autoimmune thyroiditis) is the leading cause in non–iodine-deficient regions. Primary hypothyroidism occurs with thyroid gland disorders, while the central type arises from pituitary and hypothalamic conditions. Thyroid hormones are integral in metabolic processes and in the development of the brain and other organs. Congenital hypothyroidism can result in significant mental disability due to the loss of thyroid hormones. The features of acquired hypothyroidism also reflect the effects of slowed organ function, such as fatigue, bradycardia, cold intolerance, and exertional dyspnea. Diagnosis is by thyroid function testing. Elevated thyroid stimulating hormone and low free thyroxine (T4) levels are noted. Treatment is with synthetic T4.

Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) are serious, acute complications of diabetes mellitus. Diabetic ketoacidosis is characterized by hyperglycemia and ketoacidosis due to an absolute insulin deficiency. Hyperosmolar hyperglycemic state occurs due to a relative deficiency of insulin or insulin resistance, leading to severe hyperglycemia and elevated serum osmolality. Triggering factors include inadequate insulin therapy, underlying infection, concurrent medical illness, or drug side effects. Diabetic ketoacidosis patients tend to be younger, with type 1 diabetes, who present with acute symptoms, including abdominal pain, nausea, and vomiting. On the other hand, HHS patients are generally older, with type 2 diabetes, and will have gradual onset of symptoms, including altered mental status and neurologic changes. Both sets of patients will have polyuria, polydipsia, and evidence of severe dehydration. Diagnosis is based on laboratory values demonstrating hyperglycemia with ketoacidosis or hyperosmolality. Management involves aggressive fluid rehydration, insulin therapy, and correction of electrolyte abnormalities.

The hyperosmolar hyperglycemic state is characterized by severe hyperosmolality, hyperglycemia, and dehydration. Patients in a hyperosmolar hyperglycemic state do not have ketoacidosis. Diabetic ketoacidosis, on the other hand, is characterized by hyperglycemia, dehydration, and acidosis due to ketone bodies accumulation in the blood; thus, the condition was also known as hyperosmolar non-ketotic state (HONKS) or non ketotic hyperosmolar states (NKHS)

Diabetic ketoacidosis is a common problem in type 1 diabetics and can be the presenting feature of newly-diagnosed diabetes. The typical patient with diabetic ketoacidosis is an adolescent or a child who is ill and who is presenting to the emergency department. In this article, you will gain a great overview of the diabetic management at the emergency department.

Hyperkalemia is defined by the serum potassium level when it is higher than 5.5mEq/L. It is usually an incidental finding in the general population but affects 10 % of the hospitalized patients. Severe hyperkalemia is rare but catastrophic as it causes respiratory paralysis, generalized muscle paralysis and cardiac arrest.