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Department of Pediatrics : Academic Divisions : Emergency Medicine : Resident Manual : Endocrine Emergencies

I. Hypoglycemia
II. Hypocalcemia
III. Hypercalcemia
IV. Hypomagnesemia
V. Adrenal Insufficiency
VI. Congenital Adrenal Hyperplasia Salt-Watering Crisis
VII. Thyroid Storm/Thyrotoxicosis
VIII. DKA


I. Hypoglycemia:

  • Emergency management (e.g., seizure, dysrhythmia):
    • > 6 mos: 2-4 cc/kg D25 IV/IO or < 6 mos 5 cc/kg D10 IV/IO, then,
    • D10W at 5-8mg/kg/min in infants, 3-6mg/kg/min in older children
  • With fatty acid oxidation disorder, may require 10-20mg/kg/min
  • In hyperinsulinism, may require >15mg/kg/min

II. Hypocalcemia:

  • Check phos, Mg, PTH prior to treatment
  • Give 1-2cc/kg 10% calcium gluconate IV over 30 minutes
  • Recheck calcium q 4-6hr, repeat as needed
  • Put pt. on monitor when giving IV Ca. Use IV route only when indicated, e.g., tetany, seizure

III. Hypercalcemia:

  • NS and KCl at 1.5 maintenance after adequate hydration (e.g. 20cc/kg NS bolus)
  • Lasix 2mg/kg IV q 6hr if needed following forced diuresis (watch for renal calcinosis)
  • Glucocorticoid (second line treatment) at 2mg/kg/day (decreases absorption of Ca)
  • Calcitonin 2-8 U/kg/day (IV/SC/IM) q 6-12 hr (transient effects)
  • Peritoneal dialysis
  • Cellulose sodium phosphate: Calcibind, 3-4 doses to decrease intestinal absorption

IV. Hypomagnesemia:

  • 6 mg elemental Mg++/kg IM (MgSO4, 50 mg elemental Mg/ml) or IV if severe (give over one hour with monitor)
  • Magnesium sulfate 50% elemental Mg++ (IM, IV)
  • Magnesium hydroxide (MOM) 41.7%
  • Magnesium gluconate 5.9%
  • 1mM = 24.3 mg = 2 mEq
  • Oral MgSo4: 0.2 - 1.2cc/kg/day (10-60mg/kg/day elemental Mg)

V. Adrenal Insufficiency:

  • IVF: 20cc/kg NS IV bolus; use normal saline and avoid potassium solutions (such as LR) at least initially since patients often have a mineralocorticoid deficiency (aldosterone) as well. Patients will present with decreased sodium levels and elevated potassium levels (although less frequently if due to secondary hypoadrenalism). Next, replace deficit with maintenance fluids over 24 hours
  • Hypoglycemia: 0.5gm/kg dextrose over 5-10 minutes, then 0.5gm/kg/hr (5cc/kg/hr D10W)
  • Cortisol replacement:
    • Hydrocortisone 2 mg/kg IV immediately
    • Outpatient stress dose oral hydrocortisone for illness: triple/quadruple dose of hydrocortisone

VI. Congenital Adrenal Hyperplasia Salt-Watering Crisis

  • 20cc/kg NS then 1.5 times maintenance with NS
  • Hydrocortisone (Solucortef) stat:
    • 2 mg/kg IV, or
    • < 2yo: 25 mg
    • 2-8 yo: 50 mg
    • > 8 yo: 100 mg

VII. Thyroid Storm/Thyrotoxicosis:

  • Labs: Free T4, T3, TSH
  • High dose PTU 200 - 400 mg q 6 hr
  • ß-blocker
  • Glucocorticoids are rarely needed
  • Cooling blanket
  • IVF if dehydrated

VIII. DKA

The most recent guidelines were published in May 2006 in Diabetes Care. It is a consensus statement on management of DKA in the ED. Many of their recommendations are listed below. Wolfsdorf et al. Diabetes Care 29(5) May 2006 1150-1159.

Goals of Treatment

  • Correct dehydration
  • Restore normoglycemia
  • Correct acidosis and reverse ketosis
  • Avoid complications of treatment
  • Identify and treat precipitating event/ factors


Treatments

  • Admission labs: electrolytes (including HCO3), VBG (ABG if critically ill), serum glucose and bedside glucose, ua (for ketones), Ca, Mg, phos, Hgb A1c, ECG if K > 6.0, CBC, ß-HCG (if indicated).
  • New onset: anti-islet, anti-insulin, and anti-GAD antibodies, ICA-512
  • Mild: v pH < 7.30, bicarbonate < 15 mmol/L
  • Moderate: v pH < 7.20, bicarbonate < 10mmol/L
  • Severe: v pH < 7.10, bicarbonate < 5mmol/L
  • Fluids (AVOID CEREBRAL EDEMA):
    • Expect 10% dehydration
    • 10-20 cc/kg NS bolus IV, to be given over 1-2 hours, repeat if hemodynamically unstable
    • Correct deficit over 24-48 hours
    • Post bolus, use NS for first 4-6 hrs, then change to 1/2 NS with electrolytes for 48+ hours
    • If Na < 132, use NS until > 132 and replace deficit more slowly
  • Insulin:
    • IV continuous drip of regular insulin at 0.1U/kg/hr (discard first 50cc, as insulin binds to tubing)
    • No need for initial IV bolus. It is not necessary and may increase the risk of cerebral edema
    • In infants, start with 0.05U/kg/hr if pH > 7.2
    • Target decline in BS should not exceed 75-100mg/dL/hr
    • If BS is not decreasing by 75-100 mg/dl/hr, increase insulin drip by 0.05U/kg/hr until drop rate is appropriate
    • If BS < 200 but pH < 7.3, increase dextrose to D10 and keep insulin at 0.1U/kg/hr (clear acidosis before trying to reach euglycemia)
    • When pH > 7.3 and BS < 200, decrease insulin drip to 0.05U/kg/hr
    • Continue IV insulin drip for 30 minutes after administering sc regular insulin
  • Glucose:
    • Expect a decrease of at least 100-200mg/dl with fluid bolus; recheck glucose after bolus
    • Should not drop any faster than 75-100mg/dl/hr with the start of insulin (may precipitate cerebral edema)
    • Check q 1hr glucose while on insulin drip
    • Add D5 once BS < 300mg/dl or if glucose is dropping by more than 100-200mg/dl/hr
    • Increase to D10 if required to maintain insulin drip
  • Potassium:
    • Potassium drops as a result of urinary losses plus intracellular shifts with insulin, so total body deficit of 3-5mEq/kg may occur
    • Add K (post void) if < 6 normal ECG
    • Replace as 20mEq/L KCl and 20mMol/L Kphos
  • Phosphate:
    • Losses similar to potassium
    • Deficit approximately 3mEq/kg
  • HCO3
    • Use with caution only if pH < 7.1 and clinically indicated by seizure, loss of consciousness, dysrhythmias. Acidosis usually corrects with hydration and insulin. Overall, do not use.
  • Monitoring:
    • BS q 1 hr while on IVF and IV insulin
    • Neuro checks every hour or more frequently as needed
    • Electrolytes, HCO3, pH q 2-4 hrs
    • Ca, Mg, Phos q 6-8 hrs
    • I/O's, VS, BP
    • Urine dips for glucose, ketones

Cerebral edema: Higher risk populations include very young, new onset and longer duration of symptoms. It occurs in 0.5-1% of all episodes of DKA. Symptoms include headache, gradual decrease in consciousness etc. If a patient shows alteration of mental status, gives Mannitol 0.5-1mg/kg over 20 minutes or 3% NaCl 5-10cc/kg over 30 minutes then obtain STAT head CT. Decrease IVF to 2/3 MIVF.
 

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