Emergency department staff now have an authoritative guideline to consult when confronted with severe endocrine-related emergencies, thanks to the Society for Endocrinology.
Developed by the society's Clinical Committee, the guideline will assist healthcare providers in a non-endocrinology clinical setting provide proper diagnosis and treatment of these endocrine emergencies, according to editorial author Marie Freel, PhD, of the Queen Elizabeth University Hospital in Glasgow.
Published in Endocrine Connections, the guideline focuses on the top five most common endocrine-related medical emergencies: acute adrenal insufficiency, severe symptomatic hyponatremia, acute hypocalcemia, acute hypercalcemia, and pituitary apoplexy.
Acute Adrenal Insufficiency
Defined by a severe deficiency of cortisol production, adrenal insufficiency is primarily caused by disruption in the adrenal gland. This disruption can result in a drop in blood pressure and low electrolytes. The role of the emergency department healthcare provider is vital for preventing morbidity during an adrenal crisis.
This condition can be primarily caused by congenital deformity, surgical removal of the glands, or autoimmune disease. Secondary causes of the condition, which present with different symptoms, include a disruption of the pituitary gland, most often by a tumor, or by chronic steroid treatments such injections, creams, or inhalers.
Common symptoms of acute adrenal insufficiency include low blood pressure or hypotension, dizziness, fatigue, fever, confusion, abdominal pain, and lower extremity pain. In a patient with primary adrenal insufficiency, he or she might present with generalized skin hyperpigmentation, while patients with a secondary insufficiency cause will more likely present with overall paleness.
The guideline authors highlight to healthcare providers that diagnosis should not delay primary treatment if adrenal crisis is suspected. First line of treatment should be IV or IM hydrocortisone, followed by rehydration by saline IV. After initial treatment, the ED healthcare provider or endocrinologist can perform a short Synacthen test and lab work. Patients may then be properly educated on prevention, and given a hydrocortisone emergency injection kit.
Severe Symptomatic Hyponatremia
Although relatively common, severe symptomatic hyponatremia can be life threatening and needs urgent treatment. Diagnosis can be made through a clinical and biochemical assessment, but the severity of symptoms does not necessarily indicate the degree of biochemical hyponatremia. Nevertheless, the authors recommend basing treatment on physical symptoms, rather than on measured blood sodium levels.
Physical symptoms may include severe vomiting and seizures, cardiorespiratory arrest, or coma, while less severe symptoms can include nausea, headache, confusion, or mild cases may present as asymptomatic. Biochemical assessments are based on serum sodium levels of 135 mmol/L or less, which are classified as mild (130-135 mmol/L), moderate (125-129), or profound (<125).
Treatment for severe symptoms includes an immediate IV treatment of a 150-mL 3% hypertonic saline solution within the first hour to achieve a 5 mmol/L increase in serum sodium. Following treatment, the cause of hyponatremia can be identified through urine osmolality evaluation.
Acute hypocalcemia is most commonly caused by a total thyroidectomy, disrupting the parathyroid gland. Some other causes include pancreatitis, blood transfusion, or severe vitamin D deficiency. The most common signs and symptoms include seizure, heart arrhythmias, hand or foot spasms, laryngospasm, and positive Trousseau's and Chvostek's signs.
Emergency department healthcare providers of patients with serum calcium levels of less than 1.9 mmol/L should immediately administer IV calcium gluconate. In severe cases, long-term treatments such as alfacalcidol or calcitriol therapy can be beneficial. Patients with mild hypocalcemia (serum calcium levels 1.9-2.1 mmol/L) can be administered oral calcium supplements. It is vital to identify the underlying cause of the patient's hypocalcemia for providing proper treatment in mild cases.
The vast majority of acute hypercalcemia cases are caused by primary hyperparathyroidism or parathyroid malignancy. Assessment of hypercalcemia severity is based on serum calcium levels of 3.0 mmol/L or greater, which are classified as non-urgent (<3.0 mmol/L), moderate but may need treatment (3.0-3.5), or urgent (>3.5). Some of the most common clinical features include excessive thirst, renal impairment, confusion or changes in mood, anorexia, nausea, constipation, and dysrhythmias.
To prevent renal failure in urgent cases, recommended first-line treatment includes rehydration with a 0.9% saline IV (4-6 L). After saline IV, further treatments can include bisphosphonates such as zoledronic acid. Recommended alternative treatments include glucocorticoids, calcimimetics, denosumad, or calcitonin, or a parathyroidectomy if no prior treatments were effective.
Although uncommon, pituitary apoplexy is a severe, life-threatening endocrine emergency. Healthcare providers in the emergency department should be aware that this condition presents similarly to a neurological emergency. The first and most common symptom includes a severe headache, followed by decreased visual acuity, ocular palsies, fever and neck stiffness, as well as reduced consciousness. The vast majority of patients with pituitary apoplexy will have no history of a pituitary condition.
With suspected pituitary apoplexy in the emergency department, the healthcare provider should administer a hydrocortisone 100 mg IM bolus, followed by additional IM injections or IV bolus. An endocrine and biochemical assessment with full blood work should be completed, followed by an urgent MRI or pituitary CT scan. If the pituitary apoplexy diagnosis is confirmed, the patient should be referred to an endocrine and neurosurgical team to assess if surgery or other form of management is required.