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(part 1)ological EmergenciesA 16-year-old girl, Mary, presents to the emergency department with abdominal pain and vomiting. Over the last 3 months, Mary has lost weight and has been going to the toilet more frequently. On examination, she dehydrated and is hypotensive. Given the likely presentation, what is the most appropriate immediate management of Mary? a. Offer antihyperglycemic medication such as metformin b. Obtain IV access to provide 1L of 0.9% saline c. Reassure the patient and offer safety netting advice d. Immediate referral to endocrinology e. Initiate a fixed rate insulin infusion (0.1unit/kg/hr)A 16-year-old girl, Mary, presents to the emergency department with abdominal pain and vomiting. Over the last 3 months, Mary has lost weight and has been going to the toilet more frequently. On examination, she dehydrated and is hypotensive. Given the likely presentation, what is the most appropriate immediate management of Mary? a. Offer antihyperglycemic medication such as metformin b. Obtain IV access to provide 1L of 0.9% saline c. Reassure the patient and offer safety netting advice d. Immediate referral to endocrinology e. Initiate a fixed rate insulin infusion (0.1unit/kg/hr) Diabetic Ketoacidosis Pathophysiology Sub-heading • Uncontrolled lipolysis ➔ • Text increased free fatty acids and ketone bodies ➔ ketoacidosis • Common precipitants: infection, missed insulin doseClinical Features Diagnostic Criteria: • 2 common signs for exam questions: acetone (pear drop) breath and Kussmaul respiration • Kussmaul respiration: deep, laboured breathing • Other signs: abdominal pain, N+V, polyuria, polydipsia, confusion A-E approach Management Early senior involvement Obtain IV access via 2 wide bore cannulas BEDSIDE BLOODS IMAGING - Urine dip: glycosuria, - ABG: assess pH and -Used to screen for ketonuria bicarbonate levels underlying infection if - Capillary blood glucose - FBC, CRP, U&E’s indicated (e.g. CXR) - Blood cultures -ECG FLIP! Fluids 1. 1L of 0.9% NaCL 2. Insulin infusion rate: 0.1units/kg/hr Insulin 3. Correction of electrolyte disturbance: providing K+ Potassium replacementFollowing Mary’s acute presentation, she is stabilized with IV fluids, a fixed rate of insulin and potassium replacement. 4 hours later, she reports experiencing a severe headache and dizziness. The nurse looking after Mary notes that Mary’s GCS has reduced from 15 to 13. Given the likely cause of the headache, what is the most appropriate next step in her management? a. Stop the fixed rate insulin infusion b. Arrange for urgent imaging (i.e. CT head) c. Offer non-opioid analgesia (e.g. ibuprofen) d. Take an ABG to assess oxygenation e. Reassure the patient and continue with fluidsFollowing Mary’s acute presentation, she is stabilized with IV fluids, a fixed rate of insulin and potassium replacement. 4 hours later, she reports experiencing a severe headache and dizziness. The nurse looking after Mary notes that Mary’s GCS has dropped from 15 to 13. Given the likely cause of the headache, what is the most appropriate next step in her management? a. Stop the fixed rate insulin infusion b. Arrange for urgent imaging (i.e. CT head) c. Offer non-opioid analgesia (e.g. ibuprofen) d. Take an ABG to assess oxygenation e. Reassure the patient and continue with fluidsCerebral Oedema - a potential consequence of DKA management - In children and young adults, cerebral oedema is the most common cause of death - Raised intracranial pressure (ICP) → brainstem compression, coning and death - Risk factors for cerebral oedema in children include: ➢Significant acidosis ➢Excessive fluid administration ➢Early insulin therapy within the first 4 hoursA 56 year old man, Mark, has presented to the emergency department with a worsening headache and increasing confusion. On examination, he is tachycardic and is showing clinical signs of dehydration (e.g. reduced skin turgor). Mark has a history of type 2 diabetes, for which he takes metformin, gliclazide and empagliflozin. Mark’s notes reveal he is poorly compliant with his medication. Given the likely diagnosis, which diagnostic parameter is most important to monitor? a. Serum ketones b. Urine osmolality c. Serum osmolality d. Serum blood glucose e. Serum inflammatory markersA 56 year old man, Mark, has presented to the emergency department with a worsening headache and increasing confusion. On examination, he is tachycardic and is showing clinical signs of dehydration (e.g. reduced skin turgor). Mark has a history of type 2 diabetes, for which he takes metformin, gliclazide and empagliflozin. Mark’s notes reveal he is poorly compliant with his medication. Given the likely diagnosis, which diagnostic parameter is most important to monitor? a. Serum ketones b. Urine osmolality c. Serum osmolality d. Serum blood glucose e. Serum inflammatory markersHyperosmolar hyperglycaemic state (HHS)Hyperosmolar hyperglycaemic state (HHS) without ketoacidosismmol/L) Clinical features: - Reduced GCS - Dehydration - Confusion, lethargy, HHS headache - ‘Poly’ symptoms Hyperosmolality (> 320 mOsmol.Hypovolemia - Seizures Serum osmolality Management = 2Na+ + glucose + urea Similar principles to DKA management! 1. Fluid replacement- IV 0.9% sodium chloride is first-line *Fixed rate insulin (ONLY if ketonemia or blood Raised serum osmolality= hyper glucose not falling with IV fluids)* viscosity 2. Potassium replacement ➔Thrombosis 3. Anticoagulation: ALL patients should receive prophylactic LMWH ➔HHS mortality HIGHER than DKA ➔Regular monitoring advised!A 42 year old woman, Judy, is brought in by her husband following a ‘funny turn’ 2 hours ago. She is visibly sweating and shaking. Her husband reveals she has a history of type 1 diabetes, for which she is taking a basal-bolus insulin regimen. Given that she is conscious and able to swallow, what is the most appropriate initial management? a. Long acting carbohydrate (e.g. piece of toast) b. IM glucagon c. IV dextrose 20% d. Fast acting carbohydrate (e.g. glucose gel) e. MetforminA 42 year old woman, Judy, is brought in by her husband following a ‘funny turn’ 2 hours ago. She is visibly sweating and shaking. Her husband reveals she has a history of type 1 diabetes, for which she is taking a basal-bolus insulin regimen. Given that she is conscious and able to swallow, what is the most appropriate initial management? a. Long acting carbohydrate (e.g. piece of toast) b. IM glucagon c. IV dextrose 20% d. Fast acting carbohydrate (e.g. glucose gel) e. Metformin Hypoglycaemia (< 4mmol.L) Clinical Features Causes Drugs: - Insulin - Sulphonylureas - Beta-blockers Autonomic Neuropsychiatric - Chronic alcohol abuse - Tachycardia - Agitation Hormonal deficiency: - Adrenal insufficiency - Tremor - Fatigue - Anxiety - Blurred vision (e.g. Addison's) - N+V - Reduced GCS - Hypothyroidism - Sweating Critical illness: - Sepsis - Burns - Liver failure Hypoglycaemia Key investigation: capillary blood glucose Conscious and able to swallow Reduced consciousness/ unable to swallow/ emergency treatment 1 line: fast acting carbohydrate IM glucagon/ IV glucose ➢ glucose tablets/gels/fruit juice Once glucose levels > 4mmol/L, offer long acting carbohydrateA 9 year old boy, Salim, presents to the emergency department with left foot pain. On examination, the foot appears to be red, swollen and hot to touch. Salim is also pyrexial (38.4 degrees). Salim has a history of sickle cell disease and a documented allergy to penicillin. The registrar suspects Salim has presented with a bone infection. Given the likely diagnosis, what is the most likely causative organism? a. Group A streptococcus b. E Coli c. Salmonella Typhi d. Staphylococcus Aureus e. Coxsackie AA 9 year old boy, Salim, presents to the emergency department with left foot pain. On examination, the foot appears to be red, swollen and hot to touch. Salim is also pyrexial (38.4 degrees). Salim has a history of sickle cell disease and a documented allergy to penicillin. The registrar suspects Salim has presented with a bone infection. Given the likely diagnosis, what is the most likely causative organism? a. Group A streptococcus b. E Coli c. Salmonella Typhi d. Staphylococcus Aureus e. Coxsackie AFollowing an MRI scan, Salim is being treated as a confirmed case of osteomyelitis. The registrar asks you to look up the treatment options in the BNF. Given Salim’s history, which antibiotic would be most appropriate to initiate? a. Clarithromycin b. Flucloxacillin c. Amoxicillin d. Clindamycin e. MetronidazoleFollowing an MRI scan, Salim is being treated as a confirmed case of osteomyelitis. The registrar asks you to look up the treatment options in the BNF. Given Salim’s history, which antibiotic would be most appropriate to initiate? a. Clarithromycin b. Flucloxacillin c. Amoxicillin d. Clindamycin e. Metronidazole Osteomyelitis Haematogenous Non-haematogenous Risk factors: sickle Risk factors: diabetic foot, cell, IVDU, HIV, IE peripheral arterial disease Clinical features: pain, fever, reduced range of movement, local inflammation Periosteal reaction in osteomyelitis of the 1st MTP joint Osteomyelitis: facts for exams • Commonest underling organism= staphylococcus aureus • Except in sickle-cell patients= salmonella typhi • Key diagnostic investigation= MRI • Other important investigations: wound swab, blood cultures and X-ray of affected area • Management 6-week antibiotic treatment (flucloxacillin/ clindamycin)Thank you for attending! Fill in the feedback form to get access to the slides! Upcoming Events: th • Wednesday 29 March – Endocrine Emergencies Part 2 • Monday 3 April – Endocrine Pharmacology Part 1 • Wednesday 5 April – Endocrine Pharmacology Part 2 th • Monday 10 April – SBA Quiz