Royal College: Emergency Medicine > Metabolism & Endocrine > Flashcards

Metabolism & Endocrine Flashcards

This deck covers Chapters 116-120 in Rosens, comprising all of endocrinology, electrolyte disturbances, and acid-base physiology. (84 cards)

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1
Q

What is Conn’s syndrome? Is the K elevated?

A

Conn’s Syndrome

  • Primary hyperaldosteronism
  • Hypernatremia
  • Hypokalemia
  • Hypertension
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2
Q

List 8 causes of hypophosphatemia.

A
  1. Malnourished
  2. EtOH abuse
  3. Hyperventilation
  4. Sepsis
  5. NMS
  6. Insulin
  7. Diuretics
  8. Burns
  9. Hyperparathyroidism
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3
Q

List FOUR tests that can help diagnose adrenal insufficiency.

A

To Diagnose

  1. AM Cortisol
  2. AM ACTH
    * Differentiates 1* from 2* (1* = high ACTH)
  3. ACTH Stimulation Test
    * Baseline cortisol
    * Give 250mcg of ACTH, measure again at 30/60m
    * If cortisol <20, gland doesn’t work (Primary AI)
    * Normal patient should double cortisol
  4. 24h Urine for 17-OH Steroids

If in doubt re: diagnosis, give dexamethasone because hydrocortisone has mineralocorticoid activity.

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4
Q

List SIX causes of a high osmolar gap.

A
  1. EtOH
  2. Methanol
  3. Isopropyl Alcohol
  4. Ethylene Glycol
  5. DKA
  6. Mannitol/Sorbitol
  7. Hyperlipidemia
  8. CKD
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5
Q

Outline your management of hypercalcemia in the ED.

A
  1. Fluids, fluids, fluids
  2. Diuretics are contentious: if you give any, make it Lasix
  3. Bisphosphonates
  4. Calcitonin 4 IU/kg
  5. Hydrocortisone (if granulomatous dz, not cancer)
  6. Remove offending agent/treat underlying condition
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6
Q

What is the formula for the anion gap? What is the correction for albumin?

A

Anion Gap

  • Na+ - (HCO3- + Cl-)

For every 10 g/L drop in albumin remove 2.5 from expected AG

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7
Q

How would you approach severely symptomatic hyponatremia and how quickly would you correct the serum sodium?

A

Severe Hyponatremia

  • Hypertonic (3%) saline 100ml over 10 mins
  • Will increase Na+ 2-3 mmol/L
  • 3% saline = 513mEq/L OR about 0.5 mEq/mL
  • Repeat q10min until seizures stop

Sodium Correction

  • Target: 120 mEq/L or until not seizing
  • Acute: 1 mEq/L/h
  • Chronic: 0.5 mEq/L/h, max 12mEq/day
  • Administer D5W and DDAVP if corrected too rapidly
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8
Q

How can the measured sodium in patients with hyperglycemia be corrected?

A

↑ Glucose 10 mmol/L causes ↓ Na+ 3 mmol/L

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9
Q

Differentiate activated hyperthyroidism from unactivated (apathetic) hyperthyroidism.

A

Activated Hyperthyroidism

  • 4th decade
  • Duration of symptoms: 8 months
  • Weight loss: 10 lbs
  • Thyroid weight 70 g
  • Eye findings: Frequent
  • CHF: Common
  • Afib: 1/3 of patients
  • Depression: Uncommon

Apathetic Hyperthyroidism

  • 7th decade (ELDERLY)
  • Duration of symptoms: 26 months
  • Weight loss: 40 lbs
  • Thyroid weight: 45 g
  • Eye findings: Rare
  • CHF: Common
  • AFib: ¾ of patients
  • Depression: Common
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10
Q

Differentiate primary and secondary adrenal insufficiency. List FIVE causes of each.

A

Primary AI = the gland has failed

  • Acute
    1. Addison’s disease (MCC in the West)
    2. TB (MCC worldwide)
    3. Waterhouse-Friederich (Neisseria)
    4. Trauma
    5. Anticoagulation
  • Chronic
    1. Addison’s
    2. TB
    3. HIV
    4. Adrenal mets
    5. Adrenalectomy
    6. Etomidate

Secondary AI = the pituitary has failed

  • Acute
    1. Sheehan syndrome
    2. Pituitary apoplexy
    3. TBI
    4. Sepsis
  • Chronic
    1. Pituitary tumor
    2. Surgery
    3. Steroids
    4. Empty Sella
    5. Brain rads
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11
Q

List SIX causes of increased ADH.

A

​SIADH and Normal

  1. Increased osmolarity (Na+)
  2. Decreased BP
  3. SAH
  4. Pain
  5. Medications (SSRI)
  6. Low pressure, low volume
  7. Caffeine
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12
Q

The anion gap takes into consideration chloride and bicarb. What are FIVE classic unmeasured anions?

A
  1. Albumin
  2. Lactate
  3. Ketones
  4. Sulfate
  5. Phosphate
  6. Organic acids
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13
Q

What is the pathophysiology of rhabdomyolysis?

A
  • Depletion of ATP (exercise, drug, trauma) causing…
  • ATP-dependent ion channel failure causing…
  • Huge increase in intracellular calcium causing…
  • Increased muscle contractility
  • Protease activity
  • Mitochondrial dysfunction causing O2 free radicals
  • Apoptosis
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14
Q

List the 6 progressive ECG changes of hyperkalemia.

A
  1. Peaked T waves
  2. Loss of P waves
  3. Widening of QRS
  4. Sine wave
  5. Vfib
  6. Asystole
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15
Q

List 6 causes of hyperkalemia.

A
  1. Hemolysis
  2. Renal failure
  3. Drugs (Spironolactone, ACEi, NSAIDs)
  4. Tumour lysis syndrome
  5. Rhabdomyolysis
  6. Digoxin toxicity
  7. Amiloride
  8. Iatrogenic
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16
Q

Give FOUR causes for falsely low anion gap.

A

High levels of unmeasured cations:

  1. Lithium
  2. Hypergammaglobulinemia (MM)
  3. Hypertriglyceridemia
  4. Bromide toxicity
  5. Hypoalbuminemia
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17
Q

List SIX triggers for DKA.

A

The 8 “I’s”

  1. Initial
  2. Insulin non-compliance
  3. Infarct (MI/CVA)
  4. Infection
  5. Incision (surgery)
  6. Insemination (pregnancy)
  7. Intoxication
  8. Iatrogenic (medication changes)
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18
Q

List SIX symptoms consistent with thyrotoxicosis.

List SIX signs consistent with thyrotoxicosis.

A

Symptoms

SOB, exercise intolerance, palpitations, weight loss, appearance change, hair loss, anxiety, temperature intolerance, restless, oligomenorrhea

Signs

Afib, proptosis, tachycardia, CHF, fever, neck swelling, bruit, tremor, hyperreflexia

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19
Q

In regards to the serum glucose, how is diabetes diagnosed?

A
  • Random plasma glucose >11.1 mmol/L
  • Fasting plasma glucose >7 mmol/L
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20
Q

List 6 drugs that have been associated with rhabdomyolysis.

A
  1. Barbiturates
  2. Benzodiazepines
  3. Colchicine
  4. Corticosteroids
  5. Isoniazid
  6. Lithium
  7. MAOIs
  8. Narcotics
  9. Neuroleptics
  10. Phenothiazines
  11. Salicylates
  12. Serotonergics
  13. Statins
  14. Theophylline
  15. TCAs
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21
Q

List EIGHT causes of respiratory alkalosis.

A

Central

  1. Head Injury
  2. Stroke
  3. Anxiety
  4. Pain
  5. ASA
  6. Pregnancy
  7. High-altitude
  8. Anemia

Pulmonary

  1. Hypoxia
  2. PE
  3. Pneumonia
  4. Asthma
  5. Pulmonary edema
  6. Mechanical ventilation
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22
Q

Explain the phenomenon of paradoxical worsening of ketosis as AKA/DKA is treated.

A
  • AKA/DKA is mostly β-hydroxybutyrate
  • As its treated, it is converted to acetoacetate
  • Urine dipstick tests acetoacetate, not β-hydroxybutyrate
  • Dip looks more positive as treatment starts
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23
Q

List TEN causes of hypercalcemia.

A

Malignancy

  • Lung
  • Multiple Myeloma
  • Bone mets

Endocrine

  • Hyperparathyroidism
  • Hyperthyroidism
  • Vitamin D excess

Granulomatous

  • Sarcoidosis
  • TB
  • Crohn’s

Drugs

  • Thiazides
  • Iatrogenic calcium

Miscellaneous

  • Paget’s
  • Dehydration
  • Rhabdomyolysis
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24
Q

What is the management of hyponatremia in the asymptomatic or mild-mod symptomatic patient?

A

Hypovolemic hyponatremia

  • NS 0.9% to correct deficit

Euvolemic hyponatremia

  • Free-water restriction

Hypervolemic hyponatremia

  • Free-water restriction and diuresis +/- dialysis
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25
List SIX causes of **metabolic alkalosis**.
**CLEVER PD** * **C**ontraction * **L**icorice * **E**ndocrine (Conn's, Cushing's) * **V**omiting * **E**xcess alkali (Antacids) * **R**efeeding/**R**enal * **P**ost-hypercapnia * **D**iuretics
26
When would you treat **hyponatremia** acutely?
**Both of:** 1. Sodium \<120 mEq/L 2. Altered, focal neuro deficits, or seizing **Treatment** * 3% saline 100 cc IV over 15 minutes (raises Na 2-3 mEq)
27
List 5 precipitants of **myxedema coma**. Who is the typical patient that will present with myxedema coma? What will their vitals be like?
**Precipitants** * Infection * Infarction * Incision (Surgery) * GI bleed * Hypoglycemia * Hypothermia * Medications **Typical Patients** * Older women * Thyroidectomy **Vitals** * Hypothermic * Bradycardic * Hypotensive * Altered
28
What are the ECG changes in **hypocalcemia**?
* Short PR * Long QT * ST depression * TWI * U wave Arrhythmia is uncommon.
29
Describe the clinical presentation of **hypocalcemia**.
**Neuromuscular** * Paresthesias * Muscle weakness * Muscle spasm * Tetany * Chvostek's and Trousseau's signs * Hyperreflexia * Seizures **Cardiovascular** * Bradycardia * Hypotension * Cardiac arrest * Digitalis insensitivity * QT prolongation **Pulmonary** * Bronchospasm * Laryngospasm **Psychiatric** * Anxiety * Depression * Irritability * Confusion * Psychosis * Dementia
30
How do you calculate how much **hypertonic saline** to administer to a patient who has severe symptoms but is not actively seizing?
**Step 1: Calculate sodium deficit** * NaDeficit = TBW \* (NaDesired - NaMeasured) * Assume TBW = 60% of weight * Assume NaDesired = 120 mEq/L **Step 2: Calculate volume of 3% saline needed** * 3% saline = 513 mEq/L * Volume (cc) = (NaDeficit/ 513) \* 1000 **Step 3: Calculate desired rate of infusion** * Rate = Volume (cc) / [(NaDesired - NaMeasured)\*2] * Assumes max safe rate = 0.5 mEq/hr **Example** A 70kg man presents twitching with a sodium of 112. Assuming this is chronic, how much and how fast will you correct him? Step 1: * NaDeficit = TBW \* (NaDesired - NaMeasured) * NaDeficit = (0.6\*70) \* (120 - 112) * NaDeficit = 42 \* 8 * NaDeficit = 336 mEq Step 2: * Volume (cc) = (NaDeficit/ 513) \* 1000 * Volume (cc) = (336/ 513) \* 1000 * Volume (cc) = 655 cc Step 3: * Rate = Volume (cc) / [(NaDesired - NaMeasured)\*2] * Rate = 655 / [(120 - 112)\*2] * Rate = 655 / 16 * Rate = 41 cc/hr for 16 hours
31
List EIGHT causes of **high anion gap metabolic acidosis**.
**MUDPILES CAT** 1. **M**ethanol/**M**etformin 2. **U**remia 3. **D**KA 4. **P**ropylene glycol/**P**araldehyde 5. **I**ron, INH 6. **L**actate 7. **E**thylene Glycol 8. **S**alicylates 9. **C**O, **C**yanide 10. **A**lcoholic Ketoacidosis 11. **T**oluene
32
How is **acid** sensed in the body? How is H+ maintained?
**pH Sensing** * Central = Medulla * Peripheral = Carotid body **H+ Homeostasis** * H/K+ renal antiporter * Carbonic anhydrase * Buffering capacity
33
What is a **delta gap**? How do you calculate it?
Used to assess if more than just HAGMA * Delta Gap: Change in AG / Change in Bicarb * Remember alphabetical **A**(G) before **B**(icarb) The ratio gives one of four results: * \<0.4 due to a pure NAGMA * 0.4 – 0.8 due to a mixed NAGMA + HAGMA * 0.8 – 2.0 due to a pure HAGMA * \>2.0 due to a mixed HAGMA + metabolic alkalosis **Here's a worked example:** * Hgb 142 WBC 17 Plt 355 * Na 136 K 5.3 Cl 115 HCO3 7 Urea 28.6 Cr 522 Glc 5.5 * Ca 2.49 PO4 1.52 Mg 1.02 Albumin 36 * EtOH \< 1 Acetaminophen \< 13 Salicylates \< 0.1 * VBG: pH 6.94 pCO2 30 HCO3 6 BE -26 * Lactate 2.4 * B-hydroxybutyrate 1.55 **Calculate the delta ratio** * Delta ratio = [AG-12] / [24-HCO3] * Delta Ratio = (14-12) / (24-7) * Delta Ratio = 0.117
34
# Define the following: * Wolff-Chaikoff Effect * Jod-Basedow Effect
**Wolff-Chaik_OFF_ Effect** * Excess iodide inhibits trapping + thyroglobulin iodination * Excess iodide blocks thyroid hormone release **Jod-Basedow Effect** * Excess iodide induces more thyroid hormone creation * Can cause hyperthyroidism in patients with multinodular goiter and Graves’ disease
35
List 5 **glucoregulatory hormones** and describe their mechanism of action.
1. **Insulin (ANABOLIC)** * Augments hepatic glucose uptake and storage * Inhibits gluconeogenesis and glycogenolysis 2. **Glucagon (CATABOLIC)** * Released by α-cells of pancreatic islets * Triggers for release: hypoglycemia; stress, trauma, infection, starvation, exercise * Increases hepatic adenyl cyclase activity = increased gluconeogenesis and glycogenolysis 3. **Epinephrine (CATABOLIC)** * Increase hepatic glycogenolysis + gluconeogenesis 4. **Cortisol (CATABOLIC)** 5. ​**GH (CATABOLIC)****​** * Neither cortisol nor GH are rapid glucose changers
36
How do you treat suspected **adrenal crisis**?
**For Patient with KNOWN AI:** * Hydrocortisone is preferred because it has intrinsic mineralocorticoid activity **For Patient with UNCONFIRMED AI:** * Dexamethasone is preferred because it does not have mineralocorticoid activity and does not interfere with the ACTH stimulation test
37
List EIGHT triggers of **thyroid storm**.
1. Infection 2. Brain bleeds 3. Head injury 4. Iatrogenic (over-medicated) 5. Amiodarone 6. Burns 7. Thyroid surgery 8. Pregnancy 9. CHF 10. PE 11. Hyperemesis
38
How would you treat **hypocalcemia** in the ED?
**If peripheral IV:** * 2 amps Calcium gluconate * 1 amp CaGluconate = 93 mg Ca **If central IV/Arrest:** * 1 amp Calcium chloride * 1 amp CaCl = 272 mg Ca **Note:** * Replace magnesium if refractory * Stop if bradycardic/AVB * Effects last 2 hours (think hyperK)
39
How do you manage **thyroid storm**?
**PCP's** * **P**ropranolol (60 mg PO) * Blocks conversion/symptoms * **C**orticosteroids (Hydrocortisone 200 mg IV) * Blocks conversion/autoimmune * **P**TU (1000 mg PO) * Blocks synthesis * **S**SKI (5 drops, 1 hour after PTU) * Blocks release
40
List the 5 most common causes of **hypokalemia**.
**Renal losses** * Diuretics **Non-renal losses** * Vomiting * Diarrhea **Decreased intake** * Malnourished * Alcoholism **Intracellular shift** * Hyperventilation * Insulin * Sympathomimetics **Endocrine** * Conn's * Cushing * Bartter's syndrome
41
Provide FIVE causes of a “**double gap**” (Anion + Osmolar).
1. Methanol 2. Ethylene glycol 3. DKA 4. AKA 5. Sepsis 6. Chronic Renal failure
42
How does **amiodarone** cause thyroid issues?
* Has iodine in it * Structurally similar to T4 * Can cause thyrotoxicosis * Directly toxic to the gland
43
List EIGHT causes of **rhabdomyolysis**.
1. Prolonged immobilization 2. Excessive exercise 3. Muscle ischemia 4. Temperature extremes * Heatstroke, NMS, MH * Hypothermia 5. Electrical current 6. Electrolyte abnormalities * HypoK/Na/Phos 7. Illicit Drugs * Opiates/Sympathomimetics 8. Post-CPR 9. Medications * Succinylcholine * Statins, Fibrates, Antipsychotics 10. Infections 11. Metabolic myopathies 12. Connective tissue disorders 13. Rheumatologic disorders * Polymyositis, dermatomyositis, Sjogren’s * SLE 14. Hypothyroidism 15. Biologic toxins * Snakebite, African honey bee
44
What are the clinical effects of **hypermagnesemia**?
**\>1.6 mmol/L** * Muscle weakness, hyporeflexia * Nausea and vomiting * Hypotension secondary to vasodilation **\>4.0 mmol/L** * Coma * Hypoventilation * Neuromuscular Paralysis * Cardiac arrhythmias, bradycardia and death
45
Outline your treatment of **DKA**, with specific doses and goals.
**1. Resuscitation** * NS 10 cc/kg, repeated until not in shock **2. Fluid Resuscitation** * NS 250 cc/hr * Add KCl once K \< 5 mmol/L AND patient has UOP * Change to D5½NS once BG drops to 15 mmol/L **3. Insulin** * Insulin R 0.1 units/kg/hr IV * No bolus * Stop when AG normal **Goals of DKA Treatment:** 1. Correct metabolic acidosis 2. Correct electrolyte abnormalities 3. Identify and Tx underlying trigger
46
What are your FIVE priorities in managing a **thyroid storm**?
1. Block conversion of T4-T3 (Steroids, Propranolol, PTU) 2. Block release of thyroid hormone (iodide) 3. Block the adrenergic effects (beta-blockers) 4. Block production of thyroid hormone (PTU/Methimazole) 5. Supportive care 6. Find inciting event
47
List 6 causes of **diabetes insipidus**.
**Central** 1. Trauma 2. Malignancy 3. Pituitary surgery 4. SAH **Nephrogenic** 1. Renal disease 2. Medications (lithium) 3. Genetic disorders **Pathophysiology** ADH causes free water reabsorption. If lacking or ineffective, you void very dilute urine.
48
List complications associated with **IV NaHCO3 therapy**.
1. Paradoxical CNS acidosis 2. Impaired oxygen delivery 3. Hypokalemia 4. Hypocalcemia 5. “Overshoot” alkalosis 6. Hypernatremia 7. Volume overload 8. Hyperosmolality
49
Name the scoring system for diagnosis of **thyroid storm**. What are the six elements of this scoring system?
**Burch-Wartofsky Score** "**T**hyroid **P**roblems **M**ake **F**atties **G**o **C**razy" 1. **T**achy 2. **P**recipitating event 3. **M**ental status 4. **F**ever 5. **G**I/hepatic 6. **C**HF \>45 points definitive 25-44 maybe \<25 prob not
50
Explain the **Somogyi phenomenon**.
High blood sugar in AM misinterpreted as not enough insulin at PM when actually they are hypoglycemic in PM and the hyperglycemia in the AM is from counterregulatory hormones.
51
List 3 types of **hypernatremia** and examples of each. How do you calculate free water deficits?
**Hypovolemia** * Check urine sodium * Low = Not drinking, critically ill, extrarenal loss * High = Diuretic **Euvolemic** * Urine Na High = Dehydrated * Urine Na Low/normal = Diabetes Insipidus **Hypervolemic - Don't need to measure the Urine** * Salt poisoning * Primary Hyperaldosteronism (Conn's) * Formula misfed babies **Water Deficit = [weight (kg) x 0.6] x [(Na level – 140) / 140]**
52
List 6 causes of **SIADH**.
1. Cancers: Small cell lung cancer 2. Infections: TB, Pneumonia 3. SAH 4. Head trauma 5. Pain 6. Nausea 7. Meningitis 8. Meds (SSRI, Haldol, Opioid, Antineoplastics)
53
List FOUR causes of **hypothyroidism**.
1. Hashimoto's 2. Neonatal 3. Drugs (Lithium, Amiodarone) 4. Central cause 5. Sheehan 6. Iodine deficiency
54
List 8 causes of **hypocalcemia**.
1. Hypoalbuminemia 2. Hyperphosphatemia 3. Hypomagnesemia 4. Hypoparathyroidism 5. Vit D deficiency 6. Respiratory alkalosis 7. Rhabdomyolysis 8. Tumour lysis syndrome 9. Massive transfusion 10. Hydrofluoric acid 11. Renal failure
55
List SIX ECG features of **hypokalemia**.
1. Prolonged QT 2. T wave flattening/inversion 3. ST depression 4. U wave 5. AV Block 6. Ectopy (PVCs) 7. Arrhythmias (Afib, Vfib, asystole)
56
List 6 causes of **hypomagnesemia**.
1. Alcoholics/malnourished/cirrhosis 2. Pancreatitis 3. GI losses – Laxatives, diarrhea, Crohn’s, UC 4. DKA – large diuresis from glucosuria 5. Renal losses * Diuretics * Aminoglycosides 6. Nephrotoxic chemotherapy 7. PPI use 8. Digoxin 9. HF toxicity 10. Bartter’s Syndrome
57
How does the **urinary sodium concentration** help in the diagnosis of euvolemic hyponatremia?
**Euvolemic hyponatremia** UNa+ \> 20mEq/L * Endocrinopathy (AI) * SIADH causing drugs * SIADH \>100 UNa+ \< 10mEq/L * Polydipsia
58
List 6 causes of **hypokalemia**.
1. Loop diuretics (HCTZ/Furosemide) 2. NS administration 3. Diet 4. RTA 1/2 5. GI losses 6. Sweating 7. Malnutrition
59
Compare and contrast HHS and DKA.
**HHS** * Glucose is comically high \>33 * Not very acidotic pH \>7.3 * They're many liters down (higher BUN) * They don't have ketones in their urine **DKA** * Hyperglycemia but usually \< 33 * Acidotic * Dehydrated less (still high BUN) * Ketones
60
Which TWO drugs should you **AVOID** in thyroid storm?
1. ASA 2. NSAIDs * These displace thyroid hormone from thyroglobulin 3. Amiodarone 4. Contrast dye * These have a high iodine load
61
Outline your management of a **glyburide overdose**. How long should they be observed?
1. Charcoal, if safe/indicated 2. POCT Glucose q1h until stable * D50 IV push, if hypoglycemic 3. Dextrose infusion 4. Octreotide 50-100 mcg IV q12h * Only if hypoglycemic 5. Observe for 24 hours
62
What are TWO features in a patient with **Addison’s disease** (primary AI) but NOT secondary AI?
1. **Hyperpigmentation** * Primary AI results in high ACTH * MSH is released with ACTH * ACTH also binds the MSH receptor 2. **Hypotension****​​** * ​​Aldosterone more affected in primary
63
What are the types of **RTA**?
**Type I – Distal RTA** * Failure of H+ excretion (H+/K+ antiporter) * Acidemia and hypokalemia * Get urinary stones, nephrocalcinosis, and bone demineralization **Type II – Proximal RTA** * Failure to reabsorb bicarb * Metabolic acidosis * Fanconi syndrome​ **Type IV – Hypoaldosteronism** * Impaired ammonium (NH4) excretion * Metabolic acidosis * Hyponatremia, hyperkalemia (opposite of Conn's) Type III is historical and was a combination of I and II. Only seen in children and never again.
64
What are the typical diagnostic criteria for **DKA**?
**Diagnosis** 1. pH \<7.3 or Bicarb \<18 2. Ketones (elevated AG) 3. Glucose \>11.1
65
List 6 causes of **Non-AG metabolic acidosis**.
**HARDUP** * **H**yperchloraemia * **A**cetazolamide, Addison’s disease * **R**enal tubular acidosis * **D**iarrhea, ileostomies, fistulae * **U**reteroenterostomies * **P**ancreatoenterostomies
66
How is **serum calcium** altered by the albumin level?
Every 10 decrease in albumin is a decrease of 0.2 calcium
67
What is your management of **severe hypermagnesemia**?
* Stop infusion of Mg (if running) * 2 amps Calcium gluconate * Dilution with IV NS * Lasix * Dialysis
68
List EIGHT causes of **thyrotoxicosis**.
1. Grave's 2. Excess Iodine 3. Autoimmune thyroiditis 4. Hashimoto's 5. Multinodular goiter 6. Toxic adenoma 7. Follicular cell carcinoma 8. Pituitary tumour 9. Teratomas/Hydatidiform moles 10. Amiodarone
69
Walkthrough the **Renin-Angiotensin-Aldosterone System** and how the body responds to a decreased intravascular volume.
* Juxtaglom cells sense less blood flow and release renin * Renin causes the release of angiotensin 1 from the liver * Angiotensin I converted to Angiotensin II in the lungs * causes smooth muscle contraction * causes adrenals to secrete aldosterone * causes the pituitary to secrete ADH * Aldosterone causes Na+ retention and K+ excretion
70
A 70 kg patient is seizing with a Na of 110. What is your treatment? How much do you think it will correct?
3% saline 100 cc over 10 min IV q10min until not seizing Each 84 cc will raise the Na by 1 mEq/K * Multiply body **water** by 2 to get cc of 3% saline to raise 1 * 70 kg \* 0.6 = 42 * 42 \* 2 = 84 cc 3% saline
71
What are FIVE treatment goals with **myxedema**?
1. Replace fluids 2. Replace electrolytes 3. Check a glucose 4. T4 300mcg IV 5. Warm them 6. Hydrocortisone 100mg IV 7. Antibiotics because they're likely septic
72
What is **normal** serum pH, pCO2 and HCO3?
* pH = 7.35-7.45 * pCO2 = 35-45 mmHg * HCO3 = 22-29 mmol/L
73
What is a **normal compensatory response** for the following? * Metabolic acidosis * Metabolic alkalosis * Respiratory acidosis * Respiratory alkalosis
**Metabolic Acidosis** * **1** loss in bicarb = **1** drop in CO2 **Metabolic Alkalosis** * **1** increase in bicarb = **0.5** increase in CO2 **Respiratory Acidosis** * **10** increase in pCO2 = **1** increase in HCO3 **Respiratory Alkalosis** * **10** loss in pCO2 = **2** loss in HCO3
74
What are the clinical features of **hypercalcemia**?
**Bones, Stones, Groans, Psychic Moans** * Stones (Renal calculi) * Bones (Osteolysis) * Moans (Abdominal pain, N/V, constipation) * Groans (PUD, pancreatitis) * Psychiatric overtones (Psychosis, depression)
75
Give a reason for a **falsely elevated AG**.
Low levels of unmeasured cations: 1. Hypomagnesemia 2. Hypocalcemia 3. Hypokalemia
76
List three types of **hyponatremia** and an approach to each.
**Hypovolemic** * Urine Na Low = GI loss, Third spacing, Pancreatitis, Burns * Urine Na Normal/High = Diuretics **Euvolemic** * Urine Na Normal/High \>40 = SIADH, AI, Hypothyroidism * Urine Na Low = Polydipsia, Beer potomania **Hypervolemic** * Cirrhosis * CHF * Renal failure
77
List 4 **metabolic/endocrine abnormalities** expected with primary adrenal insufficiency.
The adrenal gland makes: * Salt (Aldosterone) * Sugar (Cortisol) * Sex (DHEA) **Primary AI** * Hyponatremia * Hyperkalemia * Hypoglycemia * Acidosis * Hypercalcemia
78
How is **osmolality** calculated?
Osmolality = 2(Na) + Sugar + BUN + 1.25(EtOH) 2 salts and a sticky BUN + 1.25(EtOH)
79
List the **MOA** of each of these drugs: * A. Biguanides * B. Sulfonylureas * C. Thiazolidinediones * D. Meglitinides * E. Dipeptidyl peptidase 4 inhibitors * F. SGLT-2 Inhibitors
**A. Biguanides (Metformin)** * Decreases hepatic glycogenolysis **B. Sulfonylureas (Glyburide)** * Causes insulin release **C. Thiazolinediones (Rosiglitazone)** * Increase sensitivity to insulin **D. Meglitinides (Repaglinide)** * Post-prandial insulin release **E. Dipeptidyl peptidase 4 (DPP4) inhibitors (Januvia)** * Decrease insulin degradation **F. SGLT-2 Inhibitors (Dapagliflozin - Invokana)** * Decreased glucose reuptake in kidney
80
List steps in the management of **rhabdomyolysis**.
**Volume Resuscitation** * NS 2L IV then give bicarb * Target urine output is 3cc/kg/hr **Urine Alkalization** * Only if CK \>5,000 * Bicarb infusion * Target urine pH \> 6.5 and serum pH 7.4-7.45 * Not evidence-based * Discontinue if hypocalcemia, pH\>7.5, or bicarb \>30 **Mannitol** * 1 g/kg over 30 min then 5 g/h IV (120 g/day) * Controversial * Monitor osmol gap – stop if \>55mOsm/kg **Renal Replacement Therapy** * Indicated for: * Persistent acidosis * Volume overload * Hyperkalemia (not responding) * Oliguria/Anuria despite fluids
81
List 6 causes of **hypermagnesemia**.
1. Iatrogenic 2. Laxatives (Magnesium oxide) 3. Antacids 4. Dialysate 5. Bowel obstruction 6. Anticholinergics 7. Narcotics 8. Lithium 9. Hypothyroidism 10. TLS 11. Adrenal insufficiency
82
List SIX causes of **respiratory acidosis**.
**Causes of inability to breath off CO2** 1. COPD 2. Pneumonia 3. Asthma **Decreased LOC** * TBI * Brain bleed * Opioids **Neuromuscular weakness** * Myasthenia * C-spine injury (C3/4/5) * Guillain Barre
83
What are the four goals of treatment in **myxedema coma**?
1. Correct electrolytes 2. Supportive care for the patient 3. Correct underlying condition 4. Correct thyroid A lot are adrenal suppressed as well
84
Provide a formula to estimate how much **hypertonic saline** is needed to raise the serum sodium by 1 mEq/L.
* 3% saline has 513 mmol/L of sodium * ~0.5 mmol/mL or 1 mmol/2 mL * TBW = 60% of body weight * So, if you multiply TBW by 2, that's the amount in mL **Example** * A 120 kg man has 120 \* 0.6 = 72 L of water * 72 \* 2 = **144 cc 3% saline** would raise Na by 1 mmol/L
Royal College: Emergency Medicine
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