GLUCOSE
HYPOGLYCAEMIA
HYPERGLYCAEMIA
ACID BASE DISTURBANCES
METABOLIC ACIDOSIS
METABOLIC ALKALOSIS
THYROID
HYPOTHYROIDISM
HYPERTHYROIDISM
PARATHYROID
HYPERPARATHYROIDISM
See
Hypercalcaemia
HYPOPARATHYROIDISM
See
Hypocalcaemia
PHAEOCHROMOCYTOMA
ADDISONIAN CRISIS
CARCINOID CRISIS
GLUCOSE
HYPOGLYCAEMIA
Top
LOOK FOR
Sweating, tachycardia
Confusion, aggression
Reduced level of consciousness
PRECIPITATING FACTORS
Diabetics (both insulin and non insulin dependent)
Septic patients
Patients on insulin infusions
Patients on TPN: especially those where TPN is ceased
Alcoholic patients
Patients presenting with coma of unknown aetiology
Fasting, dehydration, pre or post ileus/vomiting
EMERGENCY MANAGEMENT
Give 50ml 50% dextrose IV bolus injection
Measure blood sugar with finger prick
Continue to give IV dextrose until BSL > 7mmol/L
Cease insulin infusions if applicable
Measure electrolytes (especially K+)
HYPERGLYCAEMIA
Top
LOOK FOR
Tachypnoea, air hunger
Confusion, aggression, reduced consciousness
Dehydration, hypotension, inappropriate polyuria
PRECIPITATING FACTORS
Diabetics (both insulin and non insulin dependent)
Septic patients, elderly patients, patients on TPN
Fasting, dehydration, pre or postop ileus/vomiting
EMERGENCY MANAGEMENT
Restore euvolaemia: give colloid 10 ml/kg then reassess
0.9% Saline: 15-20 ml/kg over first hour, reassess, 10 ml/kg/hr thereafter
Measure BSL, biochemistry and blood gases
If ketoacidosis: (pH < 7.1, BSL > 20mmol/L):call for help
(see also
metabolic acidosis)
Insulin infusion: 50u actrapid / 50ml saline: start 5 u/hr
Measure BSL, biochemistry and blood gases hourly
No routine indication for sodium bicarbonate
Urinary catheter in all patients, consider CVC, arterial line
Reduce insulin infusion, change to 5% dextrose when BSL < 10mmol/L
Page reference refers to the
APSF's Crisis Management Manual,
2nd Edition
Top
METABOLIC ACIDOSIS
Top
LOOK FOR
Tachypnoea, air hunger
Shock, hypotension, oliguria
PRECIPITATING FACTORS
Any prolonged shock state: cardiogenic, hypovolaemic, septic, distributive
shock
Septic patients, multiple trauma
Diabetic emergencies
Intra-abdominal sepsis, ischaemia
Hepatic, renal failure
Ureterosigmoidostomy
Catecholamine (esp. adrenaline) or salbutamol infusions
Acetazolamide
Methanol, alcohol, ethylene glycol ingestion
EMERGENCY MANAGEMENT
Treat underlying cause
Ensure adequate ventilation
Support the circulation with: volume, inotropes
Measure biochemistry: calculate anion and osmolal gap
IV NaHCO3 only indicated in bicarbonate losing states with normal anion gap, eg
renal tubular acidosis
METABOLIC ALKALOSIS
Top
LOOK FOR
Tachy-arrhythmias:
AF, SVT or VT
ECG changes:: prolonged PR interval, flat T waves, U waves
Ileus, constipation, muscle weakness, ventilatory failure
Dehydration, hypovolaemia
PRECIPITATING FACTORS
Diuretics, vomiting, ileus, diarrhoea, polyuric states
Steroids, bronchodilators, catecholamines, TPN, insulin
Hypovolaemia, dehydration
Post massive blood transfusion
Post hypercapnoeic alkalosis (ventilated ICU patients)
EMERGENCY MANAGEMENT
Treat underlying cause
If hypovolaemic, give colloid 10 ml/kg and reassess
Measure electrolytes and blood gases hourly
Consider MgSO4 0.1 - 0.2 mmol/kg IV
Consider IV KCI, phosphate
Consider IV or oral acetazolamide in euvolaemic patients
HYPOTHYROIDISM
Top
LOOK FOR
Intolerance to cold
Hypothermia, hypoglycaemia, hypotension
Dry skin ("crazy pavement") changes (chronic)
Bradycardia, confusion, coma, delayed awakening
PARTICIPATING FACTORS
Elderly patients
Previous thyroidectomy, fasting
Sepsis, infections
EMERGENCY MANAGEMENT
Maintain normotension with fluid, inotropes if required
Normothermia: Actively warm if required
ECG monitoring, consider arterial line
Give IV T3 5-20 mcg slowly, 12 hourly
Check baseline thyroid function tests
Admit to HDU/ICU postoperatively
NOTE:
Whenever possible, establish a euthyroid state prior to anaesthesia
and surgery.
HYPERTHYROIDISM
Top
LOOK FOR
Bedside signs may include fine tremor, exophthalmos, goitre
Pyrexia, tachycardia, AF, SVT
Hypercarbia, metabolic acidosis
Dehydration, hypovolaemia, hypotension
EMERGENCY MANAGEMENT
Consider malignant hyperthermia
Maintain hydration, colloid 10 ml/kg IV and reassess
Cool patient actively
Adequate sedation and analgesia
Baseline thyroid function test, frequent monitoring of electrolytes
Urinary catheter, consider CVC, arterial line
a blockade (phentolamine),
β blockade if required and patient haemodynamically
stable
Consider oral carbimazole or propylthiouracil
Admit to HDU/ICU postoperatively
PHAEOCHROMACYTOMA
Top
LOOK FOR
Paroxysmal hypertension
Tachycardia, AF, SVT, VT
Peripheral ischaemia
Hypercarbia, metabolic acidosis
PRECIPITATING FACTORS
Confirmed diagnosis
Retroperitoneal or abdominal vascular procedures
EMERGENCY MANAGEMENT
Central venous and arterial lines
Phentolamine 5-10mg IV or by infusion as required
Control the timing of surgical manipulations of the tumour
Nitroprusside (50 mg/250ml) titrate to 0.5mg/kg/24hrs
Consider MgSO4 4 gm (80 mg/kg) bolus prn
Do not give β blockers until vasodilatation achieved
Patients undergoing elective removal may require adrenaline infusion post
operatively
High dependency post operatively
ADDISONIAN CRISIS
Top
LOOK FOR
Hypotension, bradycardia, hypoglycaemia
Unresponsive to catecholamines
Low Na+, high K+
EMERGENCY MANAGEMENT
CVC, arterial line
Baseline serum cortisol
Hydrocortisone 100 mg (2 mg/kg) IV, then 6 hourly
Adrenaline infusion to maintain haemodynamics
Frequent monitoring of electrolytes
High dependency post operatively
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