Module 7: Endocrine Emergencies

Readings: Gould Ch 16, Caroline Ch 32

Key Terms
Addison's disease: primary adrenal insufficient and hypocortisolism, is a long-term endocrine disorder in which the adrenal glands do not produce
enough steroid hormones

Adrenal Glands: two glands, each one located in the region of the upper poles of each kidney and made up of an adrenal cortex and adrenal medulla

Cushing’s syndrome: a condition resulting from excessive production and release of cortisol

Diabetes Insipidus: condition characterized by large amounts of dilute urine and increased thirst

SIADH: syndrome of inappropriate antidiuretic hormone secretion is a condition in which the body makes

Diabetes mellitus: disease characterized by the body’s inability to sufficiently metabolize glucose. The condition occurs either because the pancreas
doesn’t produce enough insulin of the cells don’t respond to the effects of the insulin that is produced

Diabetic ketoacidosis: a form of acidosis in uncontrolled diabetes in which certain acids accumulate when insulin is not available

Gonads: the reproductive glands; the main source of sex hormones

Hyperglycemia: abnormally high blood glucose levels

Hyperosmolar non-ketotic coma: also known as hyperosmolar nonketoic coma (HONK) is a metabolic derangement that occurs principally in patients
with type 2 diabetes. The condition is characterized by hyperglycemia, hyperosmolarity, and an bicentennial of significant ketosis

Hypoglycemia: abnormally low blood glucose level

Hypothalamus: a small region of the brain that contains several control centers for the body functions and emotions. It is a primary link between the
endocrine system and the nervous system

Insulin Resistance: condition in which the pancreas produces enough insulin but that body cannot effectively utilize it

Myxedema coma: a rare condition that can occur in patients who have sever, untreated hypothyroidism
Pancreas: the digestive gland that secretes digestive ensues into the duodenum through the pancreatic duct. The pancreas is considered both and
endocrine and an exocrine gland

Parathyroid: function is to regulate blood calcium by secreting a hormone called parathyroid hormone in response to blood calcium levels

Pituitary gland: gland who’s secretions control, or regulate, the secretions of other endocrine glands. Often called the “master gland”

Primary and secondary adrenal insufficiency: primary is known as Addison disease. A rare condition in which the adrenal glands produce an insufficient
amount of adrenal hormones

Thyroid: large gland located at the base of the neck that produces and excretes hormones that influence growth, development, and metabolism

Thyroid storm: a rare, infection-threatening condition that may occur in patients with thyrotoxicosis. The condition is usually triggered by a stressful
even or increased volume of thyroid hormones in circulation

Thyrotoxicosis: a toxic condition caused by excessive levels of circulating thyroid hormone

Learning Outcome Notes

Review the A&P related to the Major endocrine glands are scattered throughout the body. Endocrine glands secrete hormones, which secrete into
endocrine system the blood. Exocrine glands secrete into a duct such as mucus, serous glands, or the pancreatic duct.

Hormones are chemical messengers that can be classified by action, source, or chemical structure. Following release
from an endocrine gland, hormones circulate to target cells in other glands or tissues. After acting on specific
receptors of target cells, hormones are metabolized or inactivated by the target tissues or the liver and excreted in
the kidneys.
 Most often controlled through a negative feedback mechanism
Describe the role of the Hypothalamus
components in the endocrine Small region of the brain that contains several control centers for the body functions and emotions – primary link
system: between endocrine and nervous system
Hypothalamus Pituitary Gland
Pituitary gland “master gland”
Thyroid Its secretions control the secretions of other endocrine glands
Parathyroid Located at the base of the brain and attached to the hypothalamus by thin tissue
Adrenal glands Two regions:
Pancreas  Anterior pituitary (produces and secretes)
Gonads o Growth hormone - regulates metabolic processes related to growth and adaptation to physical and
 emotional stress
o Thyroid-stimulating hormone - increases production and secretion of thyroid hormone
o Adrenocorticotropin hormone - stimulates the adrenal glands to secrete cortisol and adrenal
proteins that contribute to the maintenance of the adrenal glands
o Luteinizing hormone - ovulation, progesterone production; regulates spermatogenesis, testosterone
production
o Follicle-stimulating hormone - follicle maturation, estrogen production; spermatogenesis
o Prolactin - milk production
 Posterior pituitary (secretes but does not produce – they are synthesized in hypothalamic neurons)
o Antidiuretic hormone - controls plasma osmolality; increases permeability of the distal renal tubules
and collecting ducts, which leads to an increase in water reabsorption
o Oxytocin - contracts the uterus during childbirth and stimulates milk production
Thyroid
Secretes thyroxine, which is the body’s major metabolic hormone and stimulates energy production in cells and
increases the rate at which cells consume oxygen and use carbohydrates, fats, and proteins
Iodine is important in the formation of thyroxine – production is regulated by negative feedback mechanism that
prevents the hypothalamus from stimulating the thyroid
Calcitonin – helps maintain normal calcium levels in the blood and is secreted when serum calcium is high. It travels
to the bones and stimulates bone-building cells to absorb the excess calcium
Parathyroid
Assisted in the regulation of calcium, parathyroid hormone acts as an antagonist to calcitonin and is secreted when
serum calcium is low and stimulates the breakdown of bone to release calcium into the blood stream
Adrenal Glands
Inner (adrenal cortex) and outer portion (adrenal medulla) both secrete hormones:
 Adrenal cortex
o Regulate body's metabolism, its balance of salt and water, the immune system, and sexual function
 Corticosteroids
 Cortisol – stimulates most body cells to increase their energy production
 Mineralocorticoids
 Aldosterone - stimulates the kidneys to reabsorb sodium from the urine and excrete
potassium by altering the osmotic gradient in the blood – increases both blood
volume and blood pressure
 Adrenal medulla
 o Catecholamines - assist the body in coping with physical and emotional stress by increasing heart
rate and respiratory rates and the blood pressure by stimulating sympathetic nervous system
receptors
 Epinephrine - stimulates sympathetic nervous system receptors throughout the body and
stimulates liver to convert glycogen to glucose
 Norepinephrine - causes blood vessels and skeletal muscles to constrict
Pancreas
Digestive gland that is an endocrine and exocrine gland. Excretes digestive enzymes into the duodenum through the
pancreatic duct. Endocrine component comprises the islets of Langerhans and the main hormones are responsible
for regulation of blood glucose levels
 Glucagon - produced by the alpha cells
 Insulin - produced by the beta cells
Gonads
Main source of sex hormones
 Testes
o Androgens, most important is testosterone - regulate body changes associated with sexual
development
 Ovaries – regulation of the menstrual cycle, involved in pregnancy
o Estrogen - supports development of secondary sex characteristics
o Progesterone
Describe how diagnostic tests Levels of tropic hormones as well as the hormones secreted by the target glands must be evaluated to determine
are used for evaluating disorders
endocrine disorders  Excessive amount may come from ectopic source, such as bronchogenic cancer
Blood tests
 Check serum levels of hormone – radioimmunoassay or immunochemical methods
 Can measure the effectiveness of the hormone
Urine tests
 Determine daily levels of hormones or their metabolites
 Stimulation or suppression tests can confirm the hyperfunction of hypofunction of a gland
Scans, ultrasound and MRI can determine any lesions that may be present – biopsy to eliminate possibility of
malignancy
Describe the effect of insulin Insulin enables cells to uptake glucose and allows for the storage of glycogen, fats, and protein. The presence of
on carbohydrate, fat, and insulin causes cells to take in more glucose and use it to produce energy, also causes the liver to take in more
protein metabolism. glucose and store it as glycogen for later use by the body
Distinguish between the Diabetes mellitus - a metabolic disorder in which the body’s ability to metabolize simple carbohydrates is impaired
different types of diabetes Type 1 Diabetes Mellitus
mellitus including “Juvenile diabetes” generally develops in children, hereditary but may also be caused by environmental factors that
pathophysiology, signs & cause an autoimmune disorder
symptoms, and diagnostic  Pathophysiology – patients do not produce insulin at all and require injections of synthetic insulin to inhibit
tests. production of ketoacids in the body
o Diabetic ketoacidosis – fatal levels of ketoacids in the blood
o Strict diet control, attention to activity levels and alcohol consumption
 Complications: kidney problems, nerve damage, blindness, heart disease and stroke
Type 2 Diabetes Mellitus
Most common and sometimes called adult-onset, blood glucose levels are elevated
 Metabolic syndrome – cluster of characteristics including excessive fat in the abdominal area, elevated blood
pressure, and high levels of blood lipids
 Pancreas produces enough insulin and the body cannot effectively utilize it “insulin resistance”
Signs and symptoms
 Fatigue, nausea, frequent ruination, thirst, unexplained weight loss, blurred vision, frequent infections and
slow healing of wounds, being cranky, confused or shaky, unresponsive, seizures
Diagnostic Tests
Fasting BGL, glucose intolerance test, and the glycosylated hemoglobin (HbA1c) test are used to screen
 HbA1c is for long-term control of BGL – repeated every 3 months
Proper at-home monitoring of BGL
Urine tests for ketones for those prone to ketoacidosis
Define common treatments Depend on the cause of the problem
for endocrine disorders.  Replacement therapy, I.e. insulin in diabetes mellitus
 Removal of adenomas causing excessive secretions
 Removal of masses that cause pressure, I.e. pituitary tumor causing pressure in the skull
Describe the epidemiology, pathophysiology, assessment findings and management of patients with common endocrine system disorders
including:
1. Diabetes mellitus An insulin deficit leads to the following sequence of events:
1. Initial stage
a. Insulin deficient results in decreased transportation and use of glucose in many cells of the body
b. Hyperglycemia occurs
 c. Excess glucose spills into urine, glucosuria
d. Glucose in urine excretes osmotic pressure, resulting in large amounts of urine, polyuria
e. Dehydration from polyuria and high glucose drawing water from cells
f. Dehydration causes thirst, polydipsia
g. Lack of nutrients stimulate appetite polyphagia
2. Progressive effects – severe or prolongs insulin deficit leads to diabetic ketoacidosis
a. Lack of glucose results in catabolism of fats and proteins leading to ketones in blood
i. Ketones consist of acetone and two organic acids
ii. Excessive number of ketones leads to ketoacidosis
b. Ketoacids bind with bicarbonate buffer leading to decreased serum bicarbonate and decrease in pH
of body fluids
c. Ketonuria occurs
d. Dehydration occurs and GFR decreases and excretion of acids becomes limited resulting in
decompensated metabolic acidosis
Treatment
Diet and exercise
Oral medication to increase insulin secretion or reduce insulin resistance
 Metformin, sulfonylureas, meglitinides, thiazolidinediones, DPP-4 inhibitors, GLP-1 receptor agonists, SGLT2
inhibitors
Insulin replacement
 Rapid-onset, short-acting
 Intermediate-acting
 Slow-onset, long-acting
Chronic complications
Vascular problems: microangiopathy, marcoangiopathy
Neuropathy
Infections
Cataracts
Pregnancy complications
2. Hypoglycemia Pathophysiology
Often a result of taking too much insulin or oral diabetes medication, too little food, or both. If level of glucose in the
blood drops dramatically, the brain is starved.
Assessment findings
 Rapid heart rate, sweating, feeling of hunger progressing to further cerebral dysfunction and permanent brain
damage. Headache, mental confusion, memory loss, in coordination, slurred speech, irritability, dilated pupils, and
seizures and coma in severe cases.
 BGL <4 Mol/L
Management
Measure blood glucose, immediate treatment upon Dx
 Administer glucose orally, IV or glucagon IM
3. Hyperglycemia and Pathophysiology
diabetic ketoacidosis High glucose levels caused by excessive food intake, insufficient insulin dosages, infection or illness, injury, surgery,
and emotional stress with either rapid or gradual onset
 Diabetic ketoacidosis – life-threatening condition when acids accumulate in the body because insulin is not
available. Body uses fats to generate acids and ketones as waste products
Assessment findings
Frequent and excessive urination, similar symptoms to hypoglycemia, DKA: polyurethane, poly dips is, polyphagia,
n/v, tachycardia, Kussmaul respiration, warm/dry mucous membranes, fruity odour on breath, fever, abdominal
pain, hypotension
Management
IV with ns infusion, cardiac monitoring due to potassium levels
4. Diabetes Insipidus and Pathophysiology
SIADH Results from deficit of ADH – condition is said to be nephrogenic, when the renal tubules do not response to the
hormone. May be genetic linked or linked to electrolyte imbalance or drugs
Assessment findings
Polyuria with large volumes of dilute urine, thirst – eventually causing severe dehydration
Management
Replacement therapy for ADH
5. Hyperosmolar non- Pathophysiology
ketotic coma Metabolic derangement that occurs principally in patients with type 2 diabetes and is characterized by
hyperglycemia, hyperosmolalrity, and an absence of significant ketosis. Often develops in patients who have a
secondary illness that leads to reduced fluid intake such as infection

Hyperglycemia and hyperosmolarity lead to osmotic pedicures is resulting in further intracellular dehydration
Assessment findings
 Severe dehydration and focal or global neurological deficits: drowsiness, lethargy, delirium and coma, focal or
generalized seizures, visual disturbances, hemiparesis, and sensory deficits
Management
Treatment for dehydration and altered mental status – airway management and IV access with NS bolus
6. Primary and Pathophysiology
secondary adrenal Decreased function of the adrenal cortex and consequent underproduction of cortisol and aldosterone
insufficiency  Cortisol – helps maintain blood pressure and cardiovascular function, regulates metabolism of
carbohydrates/proteins/fats, affects glucose levels in the blood by balancing the effects of insulin and
functions as an anti-inflammatory agent by slowing the inflammatory response
 Aldosterone – regulates and maintain salt and potassium balance

Abnormal adrenal function produces abnormalities in metabolism and disturbances of salt and water balance
Primary adrenal insufficiency – Addison disease – occurs when 90% of the adrenal cortex has been destroyed, can
also be caused by adrenal destruction by TB, bacterial/viral/fungal infections, adrenal hemorrhage, or cancer
Secondary adrenal insufficiency – a lack of ACTH secretion from the pituitary gland: this causes a deficient secretion
of cortisol from the adrenal cortex as it is stimulated by ACTH
Assessment findings
Weakness, dehydration, inability to maintain adequate blood pressure or to properly respond to stress
Management
Maintaining ABC, rehydration, steroid and electrolyte replacement
7. Cushing’s syndrome Pathophysiology
Caused by an excess of cortisol production by the adrenal glands or excessive use of cortisol or other steroid
hormones, can be caused by tumors of the pituitary gland or adrenal cortex can stimulate the production of excess
hormone
 Can also be caused by large amounts of cortisol or glucocorticoid hormones for the treatment of illnesses
such as asthma, RA, systemic lupus, IBS, and some allergies
Causes disturbance of metabolism and BGL rises, protein synthesis is impaired so that body proteins are broken
down leading to loss of muscle fibers and muscle weakness
Assessment findings
Weakness and fatigue, depression and mood swings, increased thirst and urination, high BGL, hypertension, weight
gain, thinning of the skin, increased acne/facial hair growth, darkening of skin obesity; buffalo hump
Management
8. Addison’s disease Pathophysiology
 Caused by atrophy or destruction of both adrenal glands, leading to deficiency of all the steroid hormones produced
by these glands and is usually due to an autoimmune process where antibodies attack the adrenal cortex
 Body fails to regulate the content of sodium, potassium, and water in body fluids
Assessment findings
Often have increased pigmentation of the skin caused by increased secretion of hormones, weakness, lethargy,
confusion or loss of consciousness, low blood pressure, elevated temperature, severe pain in lower
back/legs/abdomen, severe vomiting and diarrhea
Management
Maintaining airway, breathing, and circulation; rehydration; will require steroid hormone and electrolyte
replacement
9. Thyrotoxicosis Pathophysiology
Toxic condition caused by excessive levels of circulating thyroid hormone and can be caused by goiters, autoimmune
disease (Grave disease), and thyroid cancer
Assessment findings
Tachycardia, increased metabolism, tremor, restlessness, diarrhea, warm/moist skin
Management
Immediate threats to life and supportive care
10. Myxedema coma Pathophysiology
Inadequate supply of and organ tissues don’t grow or mature, energy production declines, and the actions of other
hormones. Severe hypothyroidism is myxedema. All organ systems may exhibit symptoms with the severity of the
symptoms reflecting the degree of hormone deficiency, and frequently localized accumulation of mutinous material
in the skin
Myxedema coma - an extreme manifestation of untreated hypothyroidism that is accompanied by physiologic
decompensation
Assessment findings
Fatigue, feeling cold, weight gain, dry skin, sleepiness. Hallmark of myxedema coma is decreasing mental status,
hypothermia
Management
Supplemental oxygen; intubation/ventilation if respiratory drive indicates, crystalloids or vasopressor agents may be
necessary for hypotension; treat hypothermia with passive rewarding
11. Thyroid storm Pathophysiology
May occur in patients with thyrotoxicosis. Usually triggered by a stressful event or increased volume of thyroid
hormones in the circulation.
 Assessment findings
Usual hyperthyroid symptoms in addition to fever, severe tachycardia, nausea, vomiting, altered mental status, and
possibly heart failure
Management
Manage immediate threats to life and provide supportive care
Interpret laboratory blood Serum Blood Levels
analysis.  Glucose (fasting) - 3.9-5.6 mmol/L
 Adrenocortiocotropin ACTH – 3.3-15.4 pmol/L
 Cortisol 8am – 0.14-0.69 mcmol/L
 Cortisol 8pm – 0-0.28 mcmol/L
 T3 – 1.16-3 nmol/L