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2374903462020Management00Management15220953462020IV fluids (N saline and 5% dextrose), thiamine; manage withdrawalInsulin not indicated00IV fluids (N saline and 5% dextrose), thiamine; manage withdrawalInsulin not indicated2343152737485Investigation00Investigation15220952737486Bloods: ABG, raised anion gap metabolic acidosis (with metabolic alkalosis due to vomiting), ketones, glucose (may be normal, low, slightly high), U+E’s (? Na, ? K), ? lactateUrine: ketone level will not be elevated as it is acetacetone detected on this test00Bloods: ABG, raised anion gap metabolic acidosis (with metabolic alkalosis due to vomiting), ketones, glucose (may be normal, low, slightly high), U+E’s (? Na, ? K), ? lactateUrine: ketone level will not be elevated as it is acetacetone detected on this test2343151852295Pathophysiology00Pathophysiology15220951852295Chronic ETOH use ? NADH : NAD, malnourished, ? glycogen stores Lipolysis, vomiting, dehydration ? free fatty acids and ketocids and ? renal clearance of ketoacids Mostly beta-hydroxybutyric acid (detected on blood, not urine; converted to acetic acid)00Chronic ETOH use ? NADH : NAD, malnourished, ? glycogen stores Lipolysis, vomiting, dehydration ? free fatty acids and ketocids and ? renal clearance of ketoacids Mostly beta-hydroxybutyric acid (detected on blood, not urine; converted to acetic acid)2349501444625Epidemiology00Epidemiology15220951442085Very heavy ETOH users following high use in previous few days00Very heavy ETOH users following high use in previous few days237490810895Alcoholic Ketoacidosis00Alcoholic Ketoacidosis 15309851592580Cause: can be precipitated by: surgery, MI, general anaesthetic, hypoglycacemia, hypothermia, trauma, psych illness, drugs 1Y: there is an aldosterone deficiency hypovolaemia, high K adrenal haem (anticoagulants, neonates, sepsis – Freidrich-Waterhouse syndrome) Addison’s disease (80%) Autoimmune diseases (70%; eg. Antiphospholid syndrome) Surgical removal Drugs (long term steroids most common cause – recovery post-steroids takes 1-12/12; ketoconazole) Infection (TB – most common infectious cause worldwide, AIDS – mot common infectious cause in USA (20%), protozoa, CMV, HSV); 60% patients with sepsis have decr cortisol Cancer (usually 1Y; lung and lymphoma most common cause of 2Y) Congenital adrenal hyperplasia: vague presentation at 2wks; look for virilisation Other (sarcoidosis, haemochromatosis, hereditary) 2Y: aldosterone is normal euvolaemia, low K pituitary failure, hypothalamic failure, head trauma, meningitis, irradiation / post op, Sheehan syndromePathophysiology: 90% of gland must be destroyed to cause hypoadrenalismResults in: 1Y: Hypo Cl / Na / osmolality / volaemia (Na rarely <120; total body depletion + intracellular movement) Hyper K (rarely >7; extracellular mvmt + decr excretion) Non- anion gap metabolic acidosis Always consider if fluid-resistant hypotension 2Y: no volume depletion; low K; high / low Na; little other change in elecrolytes as aldosterone normalSymptoms: anorexia, nausea and vomiting, diarrhoea, abdominal pain, lethargy, weight loss, weakness, postural syncopeExamination: pigmentation if 1Y; SBP <100 with postural dropInvestigation: as above + ? creatinine, mild ? Ca (in 10-20%), mild hypoglycaemia; anti-adrenal antibodies Cortisol: within 1hr of waking; <200 = insufficiency; 200-500 = needs ACTH stimulation test ACTH stimulation test: bloods Synacthen IM bloods 30mins bloods 60mins cortisol >550 = normal; if normal response = 2Y ACTH: high = 1Y; low = 2YMng: IV fluid (may need ++); treat hypoglycaemia; treat K if needed; vasopressors may be needed If uncertain diagnosis: Dexamethasone 10mg IV stat 4mg QID If certain: hydrocortisone 250mg IV stat 100mg QID; 25mg IV if neonate, 50mg IV toddler to school child, 100mg to adolescents00Cause: can be precipitated by: surgery, MI, general anaesthetic, hypoglycacemia, hypothermia, trauma, psych illness, drugs 1Y: there is an aldosterone deficiency hypovolaemia, high K adrenal haem (anticoagulants, neonates, sepsis – Freidrich-Waterhouse syndrome) Addison’s disease (80%) Autoimmune diseases (70%; eg. Antiphospholid syndrome) Surgical removal Drugs (long term steroids most common cause – recovery post-steroids takes 1-12/12; ketoconazole) Infection (TB – most common infectious cause worldwide, AIDS – mot common infectious cause in USA (20%), protozoa, CMV, HSV); 60% patients with sepsis have decr cortisol Cancer (usually 1Y; lung and lymphoma most common cause of 2Y) Congenital adrenal hyperplasia: vague presentation at 2wks; look for virilisation Other (sarcoidosis, haemochromatosis, hereditary) 2Y: aldosterone is normal euvolaemia, low K pituitary failure, hypothalamic failure, head trauma, meningitis, irradiation / post op, Sheehan syndromePathophysiology: 90% of gland must be destroyed to cause hypoadrenalismResults in: 1Y: Hypo Cl / Na / osmolality / volaemia (Na rarely <120; total body depletion + intracellular movement) Hyper K (rarely >7; extracellular mvmt + decr excretion) Non- anion gap metabolic acidosis Always consider if fluid-resistant hypotension 2Y: no volume depletion; low K; high / low Na; little other change in elecrolytes as aldosterone normalSymptoms: anorexia, nausea and vomiting, diarrhoea, abdominal pain, lethargy, weight loss, weakness, postural syncopeExamination: pigmentation if 1Y; SBP <100 with postural dropInvestigation: as above + ? creatinine, mild ? Ca (in 10-20%), mild hypoglycaemia; anti-adrenal antibodies Cortisol: within 1hr of waking; <200 = insufficiency; 200-500 = needs ACTH stimulation test ACTH stimulation test: bloods Synacthen IM bloods 30mins bloods 60mins cortisol >550 = normal; if normal response = 2Y ACTH: high = 1Y; low = 2YMng: IV fluid (may need ++); treat hypoglycaemia; treat K if needed; vasopressors may be needed If uncertain diagnosis: Dexamethasone 10mg IV stat 4mg QID If certain: hydrocortisone 250mg IV stat 100mg QID; 25mg IV if neonate, 50mg IV toddler to school child, 100mg to adolescents2432051593215Adrenal Insufficiency00Adrenal Insufficiency ................
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