Emergency medicine clinics of North America
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The adrenal glands drive physiologic homeostasis, with dysregulation in any direction causing multisystem dysfunction. Adrenal excess states include hyperaldosteronism which manifests with refractory hypertension and electrolyte abnormalities including hypernatremia and hypokalemia. Paragangliomas including pheochromocytoma can cause multisystem end-organ dysfunction due to catecholaminergic storm, which require rapid blood pressure control with phentolamine and identification of lesions amenable to surgical resection. Adrenal insufficiency states in contrast can result in hypotension and decompensation refractory to vasopressor administration, requiring adrenal supplementation via hydrocortisone.
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Emerg. Med. Clin. North Am. · Nov 2023
ReviewTechnology and Transplants: Troubleshooting Insulin Pumps and Pancreas Transplants in the Emergency Department.
Diabetes management has continued to evolve with new treatments and technology. This article discusses the approach to evaluation and management of two distinctive subsets of patients: (1) patients who manage their diabetes with an insulin pump (artificial pancreas) and (2) patients who have received a pancreas transplant. The most current literature is reviewed and pearls and pitfalls distinctive to these two patient populations are discussed. Relevant diagnostics are reviewed with emphasis on recognition of complications faced in the emergency department management of these unique patient populations.
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Hyperosmolar hyperglycemic state (HHS) is an underrecognized diabetic emergency with high morbidity and mortality. Many features of HHS overlap with those of diabetic ketoacidosis but key differentiators for HHS are serum osmolality greater than 320 mOsm/kg, lack of metabolic acidosis, and minimal to no presence of ketones. HHS is often triggered by an underlying illness-most commonly infection but may also be triggered by stroke, acute coronary syndrome, and other acute illnesses. Treatment guidelines recommend aggressive volume-repletion of osmotic losses in addition to insulin therapy, plus treatment of the underlying cause.
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Metabolic acid-base disturbances are frequently encountered in the emergency department, and many of these patients are critically ill. In the evaluation of patients with these maladies, it is important for the emergency clinician to determine the cause, which can usually be elicited from a thorough history and physical examination. There are several mnemonics that can be used to form an appropriate list of potential causes. Most of the time, the management of these patients requires no specific treatment of the acid-base status but, rather, requires treatment of the underlying disorder that is causing the acid-base disturbance.
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Respiratory acid-base disorders are often not thought of as frequently as their metabolic cousins, which occur more frequently in the emergency department. Although most respiratory and acid-base disturbances are driven by lung pathology, central nervous system and other organ systems can and do play a role as well. Although managing the airway and appropriate mechanical ventilation may be necessary, it is akin to placing a band-aid on a large wound. It is crucial for the emergency clinician to discover the etiology of the disturbance as management depends on treating the underlying etiology to prevent worsening acid-base status.