Transcript Summary - Jones & Bartlett Learning

Chapter 23
Endocrine
Emergencies
National EMS Education
Standard Competencies
Medicine
Integrates assessment findings with principles
of epidemiology and pathophysiology to
formulate a field impression and implement a
comprehensive treatment/disposition plan for
a patient with a medical complaint.
National EMS Education
Standard Competencies
Endocrine Disorders
• Awareness that
− Diabetic emergencies cause altered mental
status.
• Anatomy, physiology, pathophysiology,
assessment, and management of
− Acute diabetic emergencies
National EMS Education
Standard Competencies
Endocrine Disorders
• Anatomy, physiology, epidemiology,
pathophysiology, psychosocial impact,
presentations, prognosis, and management
of
− Acute diabetic emergencies
− Diabetes
− Adrenal disease
− Pituitary and thyroid disorders
Introduction
• The endocrine system influences almost
every cell, organ, and function of the body.
− Disorders often display a broad range of signs
and symptoms.
− Assess thoroughly and treat immediately
to prevent life threats.
Anatomy and Physiology
• Endocrine system
− Network of glands that produce and secrete
hormones
− Maintain homeostasis
− Promote permanent structural change
Anatomy and Physiology
• Exocrine glands
− Exo: outside
− Secrete chemicals
for elimination
− Ducts carry secretions
• Endocrine glands
− Endo: inside
− Secrete/release
chemicals used inside
the body
− Release hormones
into tissue and blood
Anatomy and Physiology
• Hormones of the
endocrine system
− Released directly
into bloodstream
• Travel to target
tissues
Anatomy and Physiology
• Agonists
− Bind to a cell’s
receptor
− Trigger a
response
• Antagonists
− Bind to a cell’s
receptor
− Block agonists
Mechanisms of Hormonal
Regulation
• Hormones operate within feedback systems
to maintain an optimal operating
environment.
• Release of hormones is regulated by:
− Chemical and other hormonal factors
− Neural control
Mechanisms of Hormonal
Regulation
• Endocrine
regulation
− Maintains hormone
secretion through
negative feedback
− Example: release
of epinephrine in
response to stress
Mechanisms of Hormonal
Regulation
• Disease
− Normal cell signaling is interrupted.
− Positive feedback is given.
− System stops providing negative feedback
to regulate function.
Mechanisms of Hormonal
Regulation
• The hypothalamus and pituitary gland
− Related through the vascular system
− Hypothalamic–pituitary system controls
peripheral endocrine organs
− Hypothalamus produces its own regulatory
hormones
Components of the Endocrine
System
• Hypothalamus
− Small region of the brain
− Helps control body functions and emotions
− Links endocrine and nervous systems
Components of the Endocrine
System
• Pineal gland
− Located in the posterior of the brain’s third
ventricle
− Synthesizes and secretes melatonin
Components of the Endocrine
System
• Pituitary gland
− Secretions control other glands
− Located at the base of the brain
− Two lobes: anterior and posterior
Components of the Endocrine
System
Components of the Endocrine
System
• Thyroid gland
− Secretes thyroxine
• Stimulates energy production in cells
− Secretes calcitonin
• Helps maintain calcium levels in the blood
Components of the Endocrine
System
• Thymus gland
− Helps identify and destroy foreign intruders
− Lymphocytes: white blood cells that assist with
immunity
• Killer T cells
• Helper T cells
• Suppressor T cells
Components of the Endocrine
System
• Parathyroid glands
− Help regulate calcium
− Secrete PTH when blood calcium is low
• PTH decreases calcium released in urine.
Components of the Endocrine
System
• Adrenal glands
− Coordinate several
functions
− Two parts
• Adrenal cortex
• Adrenal medulla
Components of the Endocrine
System
• Adrenal glands
(cont’d)
− Both parts produce
different hormones.
Components of the Endocrine
System
• Pancreas
− Digestive gland
− Islets of
Langerhans
• Alpha cells secrete
glucagon.
• Beta cells secrete
insulin.
• Delta cells secrete
somatostatin.
Components of the Endocrine
System
• Pancreas (cont’d)
− When blood
glucose level falls,
glucagon is
secreted.
− When blood
glucose level rises,
insulin is secreted.
Components of the Endocrine
System
• Gonads
− Main source of sex
hormones
• Testes in men
• Ovaries in women
Patient Assessment
• Endocrine emergencies tend to affect many
organ systems.
− Do not take endocrine emergencies lightly.
Scene Size-Up
• Address hazards.
• Follow standard
precautions.
• Check the home
for medications.
Primary Assessment
• Identify and manage life threats.
• Form a general impression.
− Signs and symptoms depend on affected
hormone.
− Position may indicate severity of the condition.
− Diaphoresis is a sign of severe distress.
Primary Assessment
• Airway and breathing
− Ensure a patent airway.
− Investigate abnormal breathing sounds.
− Administer oxygen if the rate is:
• Greater than 24 breaths/min
• Less than 8 breaths/min
Primary Assessment
• Circulation
− Assess skin color, moisture, and temperature.
− Obtain blood pressure.
− If necessary:
• Administer IV.
• Replenish blood component.
Primary Assessment
• Transport decision
− Many patients should be transported to a
specialty facility.
− Provide rapid transport to the closest facility if
the patient is unstable.
History Taking
• Consider signs and symptoms.
− Undiagnosed or poorly managed diabetes may
include:
• Polyphagia
• Polyuria
• Polydipsia
History Taking
• Ascertain any allergies prior to
administering medication.
• Document all medications being taken.
• Ask females about their LMP.
Secondary Assessment
• Physical exam
− Observe appearance and position.
− Identify atypical findings.
− Finer abnormalities will help determine
treatment.
Secondary Assessment
• Goals with comatose patients:
− Determine level of consciousness.
− Look for the source of coma.
Secondary Assessment
• Vital signs
− Look for hypertension and bradycardia.
− Be alert for abnormal respiratory patterns.
− Look for pararespiratory motions.
Reassessment
• Continually reassess the patient.
− Critical patients at least every 5 minutes
− Noncritical every 15 minutes
• Manage ABCs.
• Obtain blood specimens early in patients
with diabetes.
Reassessment
• Altered mental status
− Establish either:
• An IV with 0.9% NS
• A saline lock
− Immediately determine blood glucose level.
• Initiate treatment if less than 60 mg/dL.
Reassessment
• Provide emotional support.
• Monitor comatose patient’s cardiac rhythm.
• Recheck vital signs, pupils, and level of
consciousness every 5–15 minutes.
• Record findings accurately and thoroughly.
Emergency Medical Care
• Transport for comatose patients
− Intubated: supine with cervical collar
− Not intubated: stable side position
− Increasing intracranial pressure: head elevated
to 30–45 degrees and midline
Glucose Metabolic
Derangements
• Endocrine disorders are caused by:
− Hypersecretion of a gland
− Insufficient secretion of a gland
• Glucose metabolic derangements
− Caused by dysfunction of the pancreas
Glucose Metabolic
Derangements
• Most endocrine emergencies result in:
− Compromise of the ABCs
− Improper fluid balance
− Deteriorating mental status
− Abnormal vital signs and blood glucose levels
Diabetes Mellitus
• Impaired ability to metabolize glucose
• Characterized by
• Polyphagia
• Polydipsia
• Polyuria
• Glucose: fuel for cellular metabolism
Diabetes Mellitus
• Insulin assists in:
− Metabolism of carbohydrates
− Transport of glucose into the cells
• Patients have a flaw in production or
function of insulin.
Diabetes Mellitus
• In 2010 an
estimated
25.8 million people
had diabetes.
Data from: 2007–2009 National Health Interview Survey estimates projected to the year 2010.
Diabetes Mellitus
Life-Altering Complications
from Diabetes
• Kidney failure
− Glomeruli become
sclerotic.
• Necrosis of the
papillary tissue
• Nephropathy
• Renal failure
• Heart disease or
stroke
− Lipolysis raises fat
level in the blood.
• Increased risk of
atherosclerosis and
coronary
artery disease
− Microangiopathy
restricts blood flow
Life-Altering Complications
from Diabetes
• Cerebrovascular
disease, stroke,
and hypertension
− Microangiopathy is
associated with
cerebrovascular
disease, stroke
− Hypertension is
often present.
• Eyes
− High blood
glucose levels
damage vessels.
− Cataracts form
from fructose and
sorbitol in the lens.
Life-Altering Complications
from Diabetes
• Neuropathy
− Often affects
peripheral nerves
• Diminished
sensation and
function in the
extremities
• Many conditions
can be delayed or
prevented with
lifestyle changes
and continued
management.
Type 1 Diabetes Mellitus
• Pathophysiology
− Generally affects children
− Environmental factors may be part of the cause.
− Islets of Langerhans do not produce insulin.
− Daily insulin is required by injection or pump.
Type 1 Diabetes Mellitus
• Assessment
− Assess compliance
with disease
management.
− With altered mental
status, suspect low
blood glucose
level.
− Look for sores or
infections.
Type 1 Diabetes Mellitus
• Management
− Some patients use an insulin pump.
• Alternative to injections
• Controls blood glucose levels
− Several types of insulin are available.
Type 2 Diabetes Mellitus
• Pathophysiology
− Blood glucose levels are elevated.
− Typically develops later in life
− May be related to metabolic syndrome
− Many with the disease are insulin resistant.
Type 2 Diabetes Mellitus
• Assessment
− Symptoms may include:
• Frequent urination
• Thirst
• Blurred vision
• Frequent infections
• Unresponsiveness
Type 2 Diabetes Mellitus
• Management
− Weight loss helps to control the disease.
− Food intake must be spread throughout the day.
− Medication/insulin required daily.
− Oral medications are used with some patients.
Gestational Diabetes
• Pathophysiology
− Form of glucose intolerance during pregnancy
− Increases risk of type 2 diabetes
− Resolves before delivery for most women
− May result in large babies
Gestational Diabetes
• Assessment
− High levels of glucose in the fetus cause
increased production of insulin.
− Often requires cesarean sections
• Management
− Stabilize blood glucose levels.
− Diet, exercise, blood glucose testing
Hypoglycemia
• Pathophysiology
− In persons with insulin-dependent diabetes,
often results from:
• Too much insulin
• Too little food
• Both
Hypoglycemia
• Assessment
− Patient will:
• Tremble
• Have a rapid pulse
rate
• Sweat
• Feel hungry
− Additional signs
and symptoms:
•
•
•
•
Headache
Incoordination
Slurred speech
Irritability
Hypoglycemia
• Assessment (cont’d)
− Blood glucose level drops to 45 mg/dL or less
− Suspect in any diabetic patient with:
• Bizarre behavior
• Neurologic signs
• Coma
• Management
− Treat immediately.
− Measure blood
glucose.
− Administration of
glucose with stroke
may exacerbate
cerebral damage.
Courtesy of Paddock Laboratories, Inc.
Hypoglycemia
Hypoglycemia
• Management (cont’d)
− Rule out hypoglycemia with a field glucose test.
− Administer sugar if alert and able to swallow.
− Do not use an advanced airway until you have
given the patient D50.
• 12.5 to 25 g, over at least 3 minutes
Hypoglycemia
• Management (cont’d)
− Administer glucagon IM if you cannot obtain IV
access.
− Type 1 diabetes requires oral carbohydrates or
additional glucose administration.
Hyperglycemia and Diabetic
Ketoacidosis
• Pathophysiology
− Hyperglycemia: classic symptom of diabetes
• Early signs: excessive thirst and urination
• Occurs when blood glucose exceeds 120 mg/dL
• Onset may be rapid or gradual.
• Pathophysiology
(cont’d)
− Untreated
hyperglycemia will
progress to DKA.
• Occurs when
certain acids
accumulate
because insulin is
not available
Courtesy of Leonard Crowley
Hyperglycemia and Diabetic
Ketoacidosis
Hyperglycemia and Diabetic
Ketoacidosis
• Assessment
− Hyperglycemia usually progresses slowly.
− Patients in DKA are seldom deeply comatose.
− Rely on clinical presentation.
Hyperglycemia and Diabetic
Ketoacidosis
• Assessment (cont’d)
− Signs and symptoms of DKA include:
• Polyuria, polydipsia, polyphagia
• Fruity odor on the breath
• Abdominal pain
Hyperglycemia and Diabetic
Ketoacidosis
• Management
− Insulin therapy may be delivered at the hospital.
− Monitor cardiac rhythm.
• Sharply peaked T waves may require administration
of sodium bicarbonate.
• Sine wave may require administration of calcium
chloride or gluconate.
Hyperosmolar Nonketotic
(HONK) Coma
• Pathophysiology
− Occurs primarily with type 2 diabetes
− Characterized by
• Hyperglycemia
• Hyperosmolarity
• Absence of significant ketosis
Hyperosmolar Nonketotic
(HONK) Coma
• Assessment
− Patients do not experience ketoacidosis.
− Most have a history of diabetes.
− Neurologic changes possible, such as:
• Drowsiness and lethargy
• Delirium and coma
• Focal or generalized seizures
Hyperosmolar Nonketotic
(HONK) Coma
• Management
− Address dehydration and altered mental status.
− A bolus of NS is appropriate for nearly all who
are clinically dehydrated.
− Administer D50 if the glucose level is less than
60 to 80 mg/dL.
Pancreatitis
• Pathophysiology
− Inflammation of the pancreas
• Acute form is a medical emergency
• Chronic form is a progressive disease
Pancreatitis
• Assessment
− Patient may present with:
• Flank and/or epigastric pain
• Nausea and vomiting
• Abdominal distention
− Organ failure may develop.
Pancreatitis
• Management
− Most are managed with supportive care.
− Transport patients.
− Pain management may be considered.
− Lifestyle changes are critical for chronic
pancreatitis.
Adrenal Insufficiency
• Decreased function of the adrenal cortex
− Underproduction of cortisol and aldosterone
• Results in weakness, dehydration, inability
to maintain blood pressure
• Usually well tolerated
Primary Adrenal Insufficiency
(Addison Disease)
• Pathophysiology
− Both adrenal glands atrophied or destroyed
• Leads to deficiency of steroid hormones
− Occurs when 90% of the adrenal cortex has
been destroyed
Primary Adrenal Insufficiency
(Addison Disease)
• Assessment
− Signs of chronic
disease include:
• Fatigue
• Anorexia
• Salt craving
• Muscle, joint pain
• Increased
pigmentation
Primary Adrenal Insufficiency
(Addison Disease)
• Assessment (cont’d)
− Blood volume and pressure fall.
− Sodium concentration of the blood falls.
− Blood potassium rises.
Primary Adrenal Insufficiency
(Addison Disease)
• Management
− Assess and manage ABCs.
− Initiate aggressive fluid replacement.
− Hydrocortisone is indicated in the acute
management of a crisis.
Secondary Adrenal
Insufficiency
• Pathophysiology
− Characterized by a lack of ACTH secretion from
the pituitary gland
− May result if a patient abruptly stops taking
corticosteroids
Secondary Adrenal
Insufficiency
• Assessment
− May appear suddenly (addisonian crisis)
− Chief manifestation is shock
− Symptoms may also include:
• Confusion
• Low blood pressure
• Severe pain and/or vomiting
Secondary Adrenal
Insufficiency
• Management
− Maintain ABCs, and have suction ready.
− Rehydrate and correct abnormalities.
− Check glucose level and cardiac rhythm.
Cushing Syndrome
• Pathophysiology
− Excess cortisol production or use of
corticosteroid hormones
− Characteristic changes:
• Blood glucose level rises.
• Protein synthesis is impaired.
• Bones become weaker.
Cushing Syndrome
• Assessment
− Signs and symptoms include:
• Weakness and fatigue
• Increased thirst and urination
• Low blood glucose
• Thinning and/or darkening of the skin
Cushing Syndrome
• Management
− Assess and manage ABCs.
− Prehospital treatment is generally supportive.
− Obtain blood glucose level, and administer D50
if indicated.
Adrenal Gland Tumor
• Pheochromocytoma
− Usually in the medulla
− Causes excessive release of hormones
− Combination of symptoms is common
Congenital Adrenal
Hyperplasia (CAH)
• Inadequate production of cortisol and
aldosterone
− Signs may include
• Enlarged vagina in female infants
• Signs of puberty in male infants
• Short stature and severe acne
Congenital Adrenal
Hyperplasia (CAH)
• Usually requires cortisol and/or aldosterone
replacement therapy
• Surgery can correct genital deformities.
• Dexamethasone may be prescribed to a
pregnant woman if diagnosed.
Hypothyroidism and
Hyperthyroidism
• Anterior pituitary
gland secretes
thyroid-stimulating
hormone (TSH).
• Likely to require
supplemental
oxygen
Graves Disease
• Most common cause of hyperthyroidism
• Autoimmune disorder in which the thyroid
gland hypertrophies as its activity increases
− Produces a visible mass in the neck.
− Excessive amount of thyroxine is secreted
Hashimoto Disease
• Cause of hyperthyroidism
− Result of the infiltration of T lymphocytes and
plasma cells
• Autoimmune disorder that affects TSH
receptors
Myxedema Coma
• Adult
hypothyroidism is
called myxedema.
− Often presents with
accumulations of
mucinous material
in the skin
− Slowing of
metabolic
processes
Myxedema Coma
• Symptoms
− Severity is consistent with degree of deficiency.
− May include:
• Fatigue
• Feeling cold
• Dry skin
Myxedema Coma
• Dropping hormone levels may lead to
myxedema coma.
− Often precipitated by triggers
− Hallmark is deterioration of mental status
− Consistent finding is hypothermia
Myxedema Coma
• Supplemental oxygen for hypoxia
• Intubation, ventilation may be indicated
• Monitor cardiac status.
• Passive rewarming for hypothermia
• Avoid sedatives, narcotics, anesthetics
Thyrotoxicosis
• Caused by excessive levels of circulating
thyroid hormone
• Causes may include:
− Hyperthyroidism
− Goiters
− Autoimmune disorders
Thyroid Storm
• Rare, life threatening
• Signs and symptoms may include:
− Normal signs, symptoms of hyperthyroidism
− Fever
− Severe tachycardia
− Vomiting
Hyperparathyroidism
• Increased parathyroid hormone level
− Primary causes result from the gland
− Secondary causes occur elsewhere
• Most common cause is adenoma.
Hyperparathyroidism
• Signs and symptoms
− Can be vague
− May include fatigue, weakness, vomiting
• Definitive management: remove gland
• Manage ABCs, provide supportive care
• Inadequate
production or
absence of
pituitary hormones
• Clinical
presentation
varies.
Courtesy of Leonard Crowley
Panhypopituitarism
Diabetes Insipidus
• Unable to regulate fluid due to:
− Lack of ADH (central diabetes insipidus)
− Kidneys unable to respond appropriately
(nephrogenic diabetes insipidus)
• Management may include synthetic ADH.
Inborn Errors of Metabolism
• Hereditary diseases
• Cannot transform food to energy
• Two categories of disorders
− Toxic accumulations
− Energy production or utilization
Summary
• The endocrine system influences almost
every cell, organ, and function.
• Patients exhibit a range of signs and
symptoms. Avert life threats with thorough
assessment and immediate treatment.
Summary
• The endocrine system is a network of
glands that produce and secrete hormones.
Its main function is to maintain homeostasis
and promote structural changes.
• Hormones travel through the bloodstream to
target tissues.
Summary
• The major components of the endocrine
system are the hypothalamus, pineal gland,
pituitary, thyroid, thymus, parathyroid,
adrenals, pancreas, and reproductive
organs.
• The hypothalamus links the endocrine and
nervous systems.
• The pineal gland synthesizes and secretes
melatonin.
Summary
• The secretions of the pituitary gland
regulate other endocrine glands.
• Thyroid secretes thyroxine, which
stimulates energy production in cells. It also
secretes calcitonin, which helps maintain
blood calcium levels.
• The thymus gland helps the immune system
identify and destroy pathogens and disrupt
pathogenic processes.
Summary
• Three types of T cells evolve in the thymus
and help the lymphatic system defend
against pathogens: killer T cells, helper T
cells, and suppressor T cells.
• The parathyroid gland secretes parathyroid
hormone, which helps regulate blood
calcium levels.
Summary
• The adrenal glands consist of the cortex
and the medulla. They produce hormones
that help regulate metabolism, the balance
of salt and water, the immune system, and
sexual function.
• The pancreas secretes digestive enzymes
and the hormones glucagon and insulin.
• Gonads include testes and ovaries. They
are the main source of sex hormones.
Summary
• The testes are in the scrotum and produce
androgens, including testosterone, which
regulates sexual development.
• The ovaries release eggs and secrete
estrogen and progesterone, which regulate
sexual development and help regulate the
menstrual cycle and pregnancy.
Summary
• With diabetes the ability to metabolize
glucose is impaired.
• Endocrine emergencies affect many organ
systems. Poor outcomes can result quickly.
• Most patients with type 1 diabetes do not
produce insulin and require daily injections.
• When checking vital signs, watch for
increased intracranial pressure, unusual
breathing patterns, and pararespiratory
motions.
Summary
• Management of an endocrine emergency
may require intubation, supplemental
oxygen, or infusion of dextrose.
• In type 1 diabetes, the beta cells in the
islets of Langerhans no longer produce
insulin. Blood glucose must be monitored
and insulin administered daily.
Summary
• The most common form of diabetes is type
2 diabetes.
• Hypoglycemia in a person with insulindependent diabetes is often the result of too
much insulin, too little food, or both.
• Hyperglycemia is a classic symptoms of
diabetes mellitus.
• Untreated hyperglycemia will progress to
diabetic ketoacidosis.
Summary
• HONK/HHNC is a metabolic derangement
that occurs principally with type 2 diabetes.
• Gestational diabetes is a form of glucose
intolerance during pregnancy.
• Primary adrenal insufficiency (Addison
disease) is caused by atrophy or destruction
of both adrenal glands, leading to deficiency
of the hormones they produce.
Summary
• Secondary adrenal insufficiency is a lack of
adrenocorticotropic hormone secretion from
the pituitary gland.
• Acute adrenal insufficiency is called an
addisonian crisis and may result from an
acute exacerbation of chronic insufficiency.
• Cushing syndrome is caused by excess
cortisol production or by excessive use of
corticosteroid hormones.
Summary
• Pheochromocytoma is an adrenal gland
tumor that causes excessive release of
epinephrine and norepinephrine.
• With congenital adrenal hyperplasia, the
adrenal gland produces insufficient cortisol
and aldosterone.
• Thyroid hormones are critical for cell
metabolism and organ function.
Summary
• Graves disease is the most severe and
common cause of hyperthyroidism.
• Hashimoto disease is an autoimmune
disease in which the thyroid gland is
enlarged.
• Continued decrease of thyroid hormone
levels may lead to myxedema coma.
Summary
• In a myxedema coma, reduced or absent
thyroid hormone slows metabolic
processes.
• Thyrotoxicosis is caused by excessive
levels of circulating thyroid hormone. A
thyroid storm may occur with thyrotoxicosis.
• In hyperparathyroidism, blood calcium
levels increase.
Credits
• Chapter opener: © Mark Humphrey/AP Photos
• Backgrounds: Blue—Jones & Bartlett Learning.
Courtesy of MIEMSS; Gold—Jones & Bartlett
Learning. Courtesy of MIEMSS; Red—© Margo
Harrison/ShutterStock, Inc.; Green—Courtesy of
Rhonda Beck.
• Unless otherwise indicated, all photographs and
illustrations are under copyright of Jones & Bartlett
Learning, courtesy of Maryland Institute for Emergency
Medical Services Systems, or have been provided by the
American Academy of Orthopaedic Surgeons.