Endocrine and Electrolyte Emergencies

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. 

Hypothyroidism is caused by the deficiency of T3 and T4. Hashimoto's disease (autoimmune thyroiditis) is the leading cause of hypothyroidism in non-iodine deficient regions. Clinical features of hypothyroidism are primarily due to the accumulation of matrix substances and a decreased metabolic rate. Hypothyroidism is diagnosed by the estimation of TSH and free T4. It is treated by administration of synthetic T4.

Hyperthyroidism is caused by the excess of thyroid hormones T3 and T4. Graves’ disease is the most common cause of hyperthyroidism. Clinical features of hyperthyroidism are mostly due to the increased body’s metabolic rate. Hyperthyroidism is diagnosed by estimation of TSH and free T4 and T3. It is treated by pharmacological and surgical means.