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Five new guidelines highlight signs, symptoms of life-threatening endocrine emergencies
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The Society for Endocrinology has issued clinical guidance for the treatment of five life-threatening endocrine emergencies, designed to help non-endocrinology specialists recognize these lesser-known conditions.
The guidelines cover the emergency management of acute adrenal insufficiency (adrenal crisis), severe symptomatic hyponatremia, acute hypocalcemia, acute hypercalcemia and pituitary apoplexy in adult patients, and outline the typical clinical presentation of each condition, the potential causes, treatment and management, as well as how to prevent a similar situation after emergency care.
“The clinical committee of the society felt that there was great unmet clinical need and a relative lack of authoritative and easily-accessible guidance aimed specifically at the generalist admitting physician to help safely get patients with these conditions through the early hours of an emergency admission before they could access specialist expertise,” Jeremy Turner, D.Phil, FRCP, consultant endocrinologist and clinical director at Norfolk and Norwich University Hospital and honorary professor at Norwich Medical School, told Endocrine Today. “The guidelines represent consensus from a significant number of leading clinicians in each area.”
The documents include the following recommendations for management:
Adrenal crisis — Management with hydrocortisone therapy, followed by rehydration with rapid IV infusion of isotonic saline; an endocrinologist should be consulted regarding any tapering of therapy and investigating the underlying cause of the condition.
Severe hyponatremia — Immediate treatment with hypertonic saline, irrespective of the cause. The aim, according to researchers, is to achieve a 5-mmol/L rise in serum sodium within the first hour, reducing immediate danger from cerebral edema.
Acute hypocalcemia — Administer IV calcium gluconate (initially, 10 mL-20 mL 10% calcium gluconate in 50 mL-100 mL of 5% dextrose over 10 minutes with electrocardiogram monitoring). Treatment should be followed with a calcium gluconate infusion titrated to achieve normocalcemia.
Acute hypercalcemia — Rehydration with IV 0.9% saline 4 L to 6 L in 24 hours; monitor for fluid overload if the patient is older or has renal impairment. Dialysis may need to be considered if renal failure is severe. If further treatment is required, consider IV bisphosphonates.
Pituitary apoplexy — MRI has been shown to confirm diagnosis in more than 90% of patients; pituitary CT is indicated if MRI is contraindicated or not possible. Treatment includes hydrocortisone 100 mg bolus followed by six 50-mg to 100-mg hourly intramuscular injections or 100 mg to 200 mg as an IV bolus, followed by 2 mg to 4 mg per hour continuous IV infusion. Patient should be referred to the joint neurosurgical/endocrine unit for management.
Diagnosis of some of the included conditions is often delayed, according to the clinical committee authors. Patients with pituitary apoplexy, for example, often have no previous history of a pituitary problem, and the clinical features can mimic more common neurologic conditions. In cases of both adrenal crisis and pituitary apoplexy, routine follow-up with an endocrinologist is recommended to monitor the conditions.
The guidelines were published online in Endocrine Connections. – by Regina Schaffer
References:
Arlt W, et al. Endocr Connect. 2016;doi:10.1530/EC-16-0054.
Baldeweg SE, et al. Endocr Connect. 2016;doi:10.1530/EC-16-0057.
Ball S, et al. Endocr Connect. 2016;doi:10.1530/EC-16-0058.
Turner J, et al. Endocr Connect. 2016;doi:10.1530/EC-16-0056.
Walsh J, et al. Endocr Connect. 2016;doi:10.1530/EC-16-0055.
Disclosure: The researchers report no relevant financial disclosures.