Metabolic & Electrolyte Emergencies

“Endocrine emergencies represent a group of potentially life-threatening conditions that are frequently overlooked, resulting in delays in both diagnosis and treatment – factors that further contribute to their already high associated mortality rates.”

BACKGROUND

Endocrine emergencies represent a group of potentially life-threatening conditions that are frequently overlooked, resulting in delays in both diagnosis and treatment – factors that further contribute to their already high associated mortality rates. As such, the true incidence of primary endocrine emergencies is not well defined, which is likely because the disease process is often not recognised.

Although endocrine emergencies are often encountered in patients with a known endocrinopathy, the emergency may be the initial presentation in previously undiagnosed individuals.

The mortality rate of diabetic emergencies is 2 to 20% (Raghavan et al, 2011). It is highest in the elderly with hyperglycaemic crises. Overall mortality from diabetic ketoacidosis has fallen over 20 years from 7.96% to 0.67% (Joint British Diabetes Societies Inpatient Care Group, 2010).

However, the mortality of HONK in the elderly remains at approximately 20% per episode (Hemphill et al, 2011).

Did you know?
  • 25% of all new diagnoses of diabetes mellitus will be via an initial presentation of DKA.
  • A potassium of over 10mmol/L is rarely survivable.

Metabolic abnormalities such as hyperkalemia and hyponatraemia are a common occurrence within secondary care. However, both a potentially life threatening. Failure of prompt treatment of abnormalities in potassium homeostasis can lead to life threatening arrhythmias such as VT and VF (Ahee 2000).

Many metabolic abnormalities present in a non-specific way, and specific cardiological or neurological changes are late features of severe disease. Early identification, treatment and monitoring of these disturbances are crucial in preventing complications (Ahee 2000).

A 2009 NCEPOD report identified that in 43% of cases of acute kidney injury, there was an unacceptable delay in identifying the condition and thus in it’s appropriate management (NCEPOD 2009).

21% of patients who develop AKI as an in-patient die as a result of a preventable factor. These include rapid identification of the diagnosis and early escalation. NCEPOD identified many cases where major omissions had occurred in the management of patients in acute renal failure.

Many patients present with AKI secondarily to primary insult, such as sepsis or hypovolaemia. However, recognition of this primary insult is often delayed or managed poorly (NCEPOD 2009).

Many endocrine and metabolic diagnoses present in a non-specific manner.

Always consider these diagnoses:
  • Diabetic Ketoacidosis/HONK
  • Hypoglycaemia
  • Hyper/Hypokalaemia
  • Hyper/Hyponatraemia
  • Acute Kidney Injury
  • Addison’s disease

LEARNING OUTCOMES FROM COMPLETING THE TASKS

  • Describe how diabetic emergencies present to the Emergency Department

  • Assess and propose a management plan for diabetic emergencies and their complications

  • Recognise the presentation and formulate a treatment plan for hyper/hypokalaemia

  • Recognise patients who have developed acute kidney injury in the acute setting

Tasks

Complete the following before the face-to-face session:

Task 1a: Diabetic Emergencies

Duration: 30 mins

This module provides an excellent overview on all three major diabetic emergencies. The module tends to focus on the long-term management rather than the acute, but certainly provides you with an excellent foundation on the topic. Click on the screenshot or link below.

Task 1b: Diabetic KetoAcidosis

Duration: 60 mins

Diabetic ketoacidosis (DKA) is a common presentation to the emergency department (ED), and can mimic many other disease processes. The ED physician must be able to diagnose, appropriately investigate, initiate treatment and manage complications. Click on the screenshot or link below.

Task 2: Hyperkalaemia

Duration: 7 mins

This short video by Dr Corry-Bass produced through the RCEMFOAMed network covers hyperkalaemia and its management.

Task 3: Acute Kidney Injury (AKI)

Duration: 60 mins

This is an interactive module produced by UHL in response to the NCEPOD paper on acute kidney injury. The module is very interactive and works you through a number of scenarios as well as providing useful background on the problem. Click on the screenshot.

 

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CASE DISCUSSION

We have written a series of interactive cases (wikis) with short answer questions to be answered by trainees prior to the face to face teaching sessions. Currently this is only available to East Midlands Trainees.

Answer one or two questions before attending the face-to-face teaching session. Add comments to answers already given if you think it's appropriate. We will also provide tutor comments. If you find good resources that answer a question why not include links in your comment.

Part of the face-to-face teaching will be spent discussing the case(s) below:

“A 20 year old male presents to the Emergency Department with confusion and abdominal pain. On arrival he is disorientated, confused and is unable to recollect his name or date of birth...”
“A 44 year old male presents to the Emergency Department feeling generally unwell and lethargic. He has felt this way for the last 2 months and has been sleeping longer during the day...”

ADDITIONAL RESOURCES

Here are some extra resources to review if you want more information:

DKA:

The Joint British Diabetes Society guidelines on DKA management:
 

COURSE FEEDBACK

Once you have worked through the exercises, discussed the example cases and attended the face-to-face teaching, please complete the following form:

Updated: 28th July 2016