dr miles levyinternalmedicineteaching.org/uploads/3/5/5/3/35535977/... · 2017. 5. 18. ·...
TRANSCRIPT
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Miles Levy
Consultant Endocrinologist
Leicester Royal Infirmary
East Midlands Acute Medicine Conference
24th February2016
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� Sodium
� Calcium
� Pituitary
� Thyroid
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� Mild 130-135 mmol/L
� Moderate 125-129 mmol/L
� Severe <125 mmol/L
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� Mild No symptoms
� Moderate Nausea, headache, confusion
� Severe Vomiting, low GCS, seizures
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� 35 year old man
� Neuro-surgical ward
� Berry aneurysm repair
� Intractable seizures
� GCS = 5
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� 35 year old man
� Neuro-surgical ward
� Berry aneurysm repair
� Intractable seizures
� GCS = 5
Cerebral oedema
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� Na 109 mmol/l (133-144)
� K 4.3 mmol/l (3.3-5.3)
� U 5.5 mmol/l (2.5-6.5)
� C 64 μmol/l (60-120)
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� Na 109 mmol/l (133-144)
� K 4.3 mmol/l (3.3-5.3)
� U 5.5 mmol/l (2.5-6.5)
� C 64 μmol/l (60-120)
� Na 142 mmol/L yesterday
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� Acute severe hyponatraemia
� No time for full investigation
� Urgent action needed
� Ring ITU
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Move to a Level 2 monitored environment
Administration of hypertonic 3% saline*
150 mL IV over 15 min
Repeat after 20 min if no clinical improvement
Recheck serum [Na+] at 6, 12, 24 and 48 h for
overcorrection (no more than 10 mmol/L
in 24 h)
*Hypertonic 3% saline can also be administered at 0.5–1 mL/kg/hour with frequent monitoring every 2–4 hours.
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� If life threatening situation
� Irrespective of cause hyponatraemia
� 5 mmol/L increase in first hour
� < 10mmol/ L in first 24 hours
� Must be senior decision
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� If life threatening situation
� Irrespective of cause hyponatraemia
� 5 mmol/L increase in first hour
� < 10mmol/ L in first 24 hours
� Must be senior decisionOsmotic Demyelination
Syndrome (ODS)
Cerebral Oedema
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� 74 year old lady
� AMU admission
� Increased confusion
� Weight loss few weeks
� Collapse at home
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� Na 127 mmol/l (133-144)
� K 3.8 mmol/l (3.3-5.3)
� U 3.6 mmol/l (2.5-6.5)
� C 49 μmol/l (60-120)
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� Na 127 mmol/l (133-144)
� K 3.8 mmol/l (3.3-5.3)
� U 3.6 mmol/l (2.5-6.5)
� C 49 μmol/l (60-120)
� LFTs normal
� FBC normal
� CRP 17
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� Time for full investigation
� No urgent action needed
� Make a diagnosis first
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HYPONATRAEMIA [Na+] <130 mmol/L
Consider the contexte.g. known cancer, polydipsia
Stop any offending medicationse.g. thiazide diuretics, SSRIs
Initial immediate investigation panel• Glucose• Lipids• Cortisol• Thyroid function
• Liver function• Plasma osmolality• Urine osmolality• Urine [Na+] + [K+]
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HYPONATRAEMIA [Na+] <130 mmol/L
Consider the contexte.g. known cancer, polydipsia
Stop any offending medicationse.g. thiazide diuretics, SSRIs
Initial immediate investigation panel• Glucose• Lipids• Cortisol• Thyroid function
• Liver function• Plasma osmolality• Urine osmolality• Urine [Na+] + [K+]
• Clinical context and timeline always very important
• If clinically obvious then do not need algorithm
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Assess patient’s hydration status
EUVOLAEMIAHYPOVOLAEMIA
• Reduced skin turgor• Dry membranes• Tachycardia• Low BP or postural hypotension
HYPERVOLAEMIA• Oedema• Raised JVP• LVF• Ascites
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Assess patient’s hydration status
EUVOLAEMIAHYPOVOLAEMIA
• Reduced skin turgor• Dry membranes• Tachycardia• Low BP or postural hypotension
HYPERVOLAEMIA• Oedema• Raised JVP• LVF• Ascites
• Clinical assessment of volume status is difficult
• If in doubt, give saline and see what happens
• In dehydration things will improve
• In SIADH things will worsen
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EUVOLAEMIA
Check urine [Na+]
Confirm hypotonic hyponatraemia
i.e. plasma osmolality <275 Osm/kg,urine osmolality >100 Osm/kg
Urine [Na+] >20 mmol/L: likely SIADH
Urine [Na+] <20 mmol/L: reconsider hypo/hypervolaemia
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EUVOLAEMIA
Check urine [Na+]
Confirm hypotonic hyponatraemia
i.e. plasma osmolality <275 Osm/kg,urine osmolality >100 Osm/kg
Urine [Na+] >20 mmol/L: likely SIADH
Urine [Na+] <20 mmol/L: reconsider hypo/hypervolaemia
• If urine osmolality < 100 Osm/Kg likely primary polydipsia
• If urine osmolality > 100 Osm/Kg then check urine Na
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EUVOLAEMIA
Check urine [Na+]
Confirm hypotonic hyponatraemia
i.e. plasma osmolality <275 Osm/kg,urine osmolality >100 Osm/kg
Urine [Na+] >20 mmol/L: likely SIADH
Urine [Na+] <20 mmol/L: reconsider hypo/hypervolaemia
• If urine Na > 20 mmol/L, SIADH is likely diagnosis
• If urine Na < 20 mmol/L, probably intravasular volume depletion
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Investigate underlying cause: consider CT chest / abdomen / pelvis /
head
Calculate electrolyte-free water clearance using Furst formula:
Urine [Na+] + [K+]Serum [Na+]
Urine [Na+] >20 mmol/L: likely SIADH
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Investigate underlying cause: consider CT chest / abdomen / pelvis /
head
Calculate electrolyte-free water clearance using Furst formula:
Urine [Na+] + [K+]Serum [Na+]
Urine [Na+] >20 mmol/L: likely SIADH
• If no clear cause, consider CT CAP and / or MRI brain
• Furst formula to estimate electrolyte-free water clearance
• Exclude hypothyroidism, ACTH deficiency
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Investigate underlying cause: consider CT chest / abdomen / pelvis /
head
Calculate electrolyte-free water clearance using Furst formula:
Urine [Na+] + [K+]Serum [Na+]
Urine [Na+] >20 mmol/L: likely SIADH
• If no clear cause, consider CT CAP and / or MRI brain
• Furst formula to estimate electrolyte-free water clearance
• Exclude hypothyroidism, ACTH deficiency
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� Different from primary adrenal failure
� Not mineralocorticoid deficiency
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� Different from primary adrenal failure
� Not mineralocorticoid deficiency
� Cortisol needed to excrete free water
� Deficiency causes dilutional hyponatraemia
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� Different from primary adrenal failure
� Not mineralocorticoid deficiency
� Cortisol needed to excrete free water
� Deficiency causes dilutional hyponatraemia
� Looks identical to SIADH
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HYPOVOLAEMIA• Reduced skin turgor• Dry membranes• Tachycardia• Low BP or postural hypotension
HYPERVOLAEMIA• Oedema• Raised JVP• LVF• Ascites
Urine [Na+] <20 mmol/L: reconsider hypo/hypervolaemia
Treat with 0.9% salineTreat the underlying cause e.g. cardiac
failure, renal failure, liver cirrhosis
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HYPOVOLAEMIA• Reduced skin turgor• Dry membranes• Tachycardia• Low BP or postural hypotension
HYPERVOLAEMIA• Oedema• Raised JVP• LVF• Ascites
Urine [Na+] <20 mmol/L: reconsider hypo/hypervolaemia
Treat with 0.9% salineTreat the underlying cause e.g. cardiac
failure, renal failure, liver cirrhosis
• Involve appropriate specialist for CCF, nephrotic, cirrhosis
• Loop diuretics will cause diuresis that exceeds 24h sodium loss
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<0.5: commence 1.0 L fluid restrictionCalculate electrolyte-free water clearance using Furst formula:
Urine [Na+] + [K+]Serum [Na+]
0.5–1.0: commence 0.5 L fluid restriction
>1.0: fluid restriction unlikely to be effective
Assess response after 24–48 h
Re-evaluate
If poor responseConsult with Specialist e.g. Consultant Endocrinologist
Aim for target [Na+] 130 mmol/L
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<0.5: commence 1.0 L fluid restrictionCalculate electrolyte-free water clearance using Furst formula:
Urine [Na+] + [K+]Serum [Na+]
0.5–1.0: commence 0.5 L fluid restriction
>1.0: fluid restriction unlikely to be effective
Assess response after 24–48 h
Re-evaluate
If poor responseConsult with Specialist e.g. Consultant Endocrinologist
Aim for target [Na+] 130 mmol/L
• Response to fluid restriction predicted by Furst formula
• If high Na / K in urine then kidneys cannot excrete free water
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� Treat underlying pathology
� AVP antagonists
� Demeclocycline
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� Treat underlying pathology
� AVP antagonists tolvaptan 15-30mg /day
� Demeclocycline
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� Treat underlying pathology
� AVP antagonists tolvaptan 15-30mg /day
� Demeclocycline 150-300mg tds
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� Treat underlying pathology
� AVP antagonists tolvaptan 15-30mg /day
� Demeclocycline 150-300mg tds
� Discuss with local sodium expert
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� Pigmentation
� Hyponatraemia
� Hyperkalaemia
� Hypoglycaemia
� Hypotension
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� Pigmentation
� Hyponatraemia
� Hyperkalaemia
� Hypoglycaemia
� Hypotension
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� Pigmentation
� Hyponatraemia
� Hyperkalaemia
� Hypoglycaemia
� Hypotension
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� Think of the diagnosis
� Reverse hypoglycaemia
� Hydrocortisone 100mg IV stat
� Treat hyperkalaemia
� Volume replacement
� Normal saline
� Fluid balance
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� Not pigmented
� Hyponatraemia
� No hyperkalaemia
� Looks like SIADH
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� Not pigmented
� Hyponatraemia
� No hyperkalaemia
� Looks like SIADH
� Flat cortisol response
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� Not pigmented
� Hyponatraemia
� No hyperkalaemia
� Looks like SIADH
� Flat cortisol response
� Long term steroids?
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� Not pigmented
� Hyponatraemia
� No hyperkalaemia
� Looks like SIADH
� Flat cortisol response
� Long term steroids?Pituitary tumour?
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� Not pigmented
� Hyponatraemia
� No hyperkalaemia
� Looks like SIADH
� Flat cortisol response
� Long term steroids?
� Improvement with steroids Pituitary tumour?
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� Mild 145-150 mmol/L
� Moderate 150-159 mmol/L
� Severe > 160 mmol/L
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� Pure water depletion
� Hypotonic fluid loss
� Salt gain
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� Pure water depletion elderly co-morbidities
� Hypotonic fluid loss
� Salt gain
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� Pure water depletion elderly co-morbidities
� Hypotonic fluid loss diabetes inspidus
� Salt gain
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� Pure water depletion elderly co-morbidities
� Hypotonic fluid loss diabetes inspidus
� Salt gain rarely seen
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High osmolality
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High osmolality
I am thirsty and need to drink and hang onto
more water
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High osmolality
I am thirsty and need to drink and hang onto
more water
Anti-Diuretic Hormone
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High osmolality
I am thirsty and need to drink and hang onto
more water
ADH
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High osmolality
I am thirsty and need to drink and hang onto
more water
ADH
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High osmolality
I am thirsty and need to drink and hang onto
more water
ADH
Water gets recycled
into blood stream
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High osmolality
I am thirsty and need to drink and hang onto
more water
ADH
Water gets recycled
into blood stream
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Osmolality stable again
I am thirsty and need to drink and hang onto
more water
ADH
Water gets recycled
into blood stream
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Low osmolality
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I am not thirsty any more and need to pee
Low osmolality
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I am not thirsty any more and need to pee
ADH switched off
Low osmolality
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I am not thirsty any more and need to pee
ADH switched off
Water not recycled back
into blood stream
Low osmolality
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I am not thirsty any more and need to pee
ADH switched off
Water not recycled back
into blood stream
Low osmolality
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I am not thirsty any more and need to pee
ADH switched off
Water not recycled back
into blood stream
Low osmolality
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I am not thirsty any more and need to pee
ADH switched off
Water not recycled back
into blood stream
Osmolality stable again
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ADH not produced or not working
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ADH not produced or not working
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ADH not produced or not working
Water cannot get recycled back
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ADH not produced or not working
Water cannot get recycled back
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ADH not produced or not working
Water cannot get recycled back
Osmolality dangerously high
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ADH not produced or not working
Water cannot get recycled back
Osmolality dangerously high
Raging thirst and drink huge amounts
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ADH not produced or not working
Water cannot get recycled back
Osmolality dangerously high
Raging thirst and drink huge amounts
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� 78 year old lady
� Previous pituitary tumour
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� 78 year old lady
� Previous pituitary tumour
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� 78 year old lady
� Previous pituitary tumour
� Right sided weakness
� Possible chest infection
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� Desmopressin 200 µg / day
� Hydrocortisone 10/5/5mg
� Thyroxine 100 µg
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� Nil by mouth
� CT brain NAD
� Antibiotics
� IV fluids
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� Nil by mouth
� CT brain NAD
� Antibiotics
� IV fluids
130
140
150
160
170
180
190
200
0 1 2 4 6 7 8 12 13 14 16 17 23 26
Na
Na
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� Nil by mouth
� CT brain NAD
� Antibiotics
� IV fluids
� RIP130
140
150
160
170
180
190
200
0 1 2 4 6 7 8 12 13 14 16 17 23 26
Na
Na
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HYPERNATRAEMIA [Na+] >150 mmol/L
Consider the contexte.g. known diabetes insipidus
Stop any offending medicationse.g lithium, demeclocycline
Initial immediate investigation panel• U&E, Glucose• Plasma osmolality• Urine osmolality• Monitor urine output
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HYPERNATRAEMIA [Na+] >150 mmol/L
Consider the contexte.g. known diabetes insipidus
Stop any offending medicationse.g lithium, demeclocycline
Initial immediate investigation panel• U&E, Glucose• Plasma osmolality• Urine osmolality• Monitor urine output
• If urine output low and urine osmolality > 800 osm/Kg
• Likely cause is reduced intake with co-morbidities
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HYPERNATRAEMIA [Na+] >150 mmol/L
Consider the contexte.g. known diabetes insipidus
Stop any offending medicationse.g lithium, demeclocycline
Initial immediate investigation panel• U&E, Glucose• Plasma osmolality• Urine osmolality• Monitor urine output
• If urine output high and urine osmolality low
• Consider diabetes inspidus
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• Discuss with ITU if appropriate / HDU environment
• Close monitoring of fluid balance and electrolytes
• Correction of circulating volume and water deficit
• Consider diabetes inspidus
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• Discuss with ITU if appropriate / HDU environment
• Close monitoring of fluid balance and electrolytes
• Correction of circulating volume and water deficit
• Consider diabetes inspidus
• If hypovolaemic, give normal saline until fluid replete
• Switch to 5% dextrose when euvolaemic
• At least 4 hourly serum Na checks
• If known DI, ensure desmopressin is administered
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� Mild 2.6-3.0 mmol/L
� Moderate 3.0-3.5 mmol/L
� Severe >3.5 mmol/L
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� Hyperparathyroidism or malignancy
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� Hyperparathyroidism or malignancy
� High PTH = hyperparathyroidism
� Low PTH = malignancy til proved otherwise
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History and clinical context
• Symptoms of hypercalcaemia
• Red flag symptoms and signs of malignancy
• Family history of calcium problems
• Relevant drugs or over the counter treatments
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History and clinical context
• Symptoms of hypercalcaemia
• Red flag symptoms and signs of malignancy
• Family history of calcium problems
• Relevant drugs or over the counter treatments
Symptoms of hypercalcaemia
• Polyuria and thirst
• Anorexia, nausea, constipation
• Mood disturbance and cognitive dysfunction
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History and clinical context
• Symptoms of hypercalcaemia
• Red flag symptoms and signs of malignancy
• Family history of calcium problems
• Relevant drugs or over the counter treatments
Severe hypercalcaemia
• Low GCS and coma in severe cases
• ECG changes (short QT interval)
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History and clinical context
• Symptoms of hypercalcaemia
• Red flag symptoms and signs of malignancy
• Family history of calcium problems
• Relevant drugs or over the counter treatments
Relevant drugs
• Thiazide diuretics
• Calcium / Vitamin D
• Theophylline
• Lithium
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Investigation of hypercalcaemia
U&E
Phosphate
PTH
Vitamin D
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Investigation of hypercalcaemia
U&E
Phosphate
PTH
Vitamin D
• Renal dysfunction common in severe hypercalcaemia
• Phosphate usually low in hyperparathyroidism
• Vitamin D toxicity rare in clinical practice
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� Granulomas
� Immobilisation
� Thyrotoxicosis
� Vitamin D toxicity
� Phaeochromocytoma
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First line treatment
• Rehydration with normal saline 4-6L in 24h
• Monitor fluid status and urine output
• Consider IV bisphosphonate
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First line treatment
• Rehydration with normal saline 4-6L in 24h
• Monitor fluid status and urine output
• Consider IV bisphosphonate
• Zolendronic acid 4mg over 15 minutes
• Pamidronate 30-90mg at 20mg/hour
• Bisphosphonates will affect PTH result
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First line treatment
• Rehydration with normal saline 4-6L in 24h
• Monitor fluid status and urine output
• Consider IV bisphosphonate
Second line treatment
• Prednisolone
• Calcitonin
• Calcimimetics
• Parathyroidectomy
• Zolendronic acid 4mg over 15 minutes
• Pamidronate 30-90mg at 20mg/hour
• Bisphosphonates will affect PTH result
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First line treatment
• Rehydration with normal saline 4-6L in 24h
• Monitor fluid status and urine output
• Consider IV bisphosphonate
Second line treatment
• Prednisolone
• Calcitonin
• Calcimimetics
• Parathyroidectomy
• Steroids if lymphoma or granuloma
• Cinacalcet (calcimimetic)
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� If young or recurrent consider MEN-1
� If severe consider parathyroid carcinoma
� If mild and family history exclude FHH
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� Mild Ca > 1.9 mmol/L no symptoms
� Severe Ca < 1.9 mmol/L symptoms
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� Can be life threatening
� Rate of change very important
� IV calcium mainstay of inpatient treatment
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Peri-oral and digital parasthesia
Trousseau’s / Chvostek’s sign
Tetany and carpo-pedal spasm
Laryngospasm
ECG changes (prolonged QT interval)
Seizures
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Peri-oral and digital parasthesia
Trousseau’s / Chvostek’s sign
Tetany and carpo-pedal spasm
Laryngospasm
ECG changes (prolonged QT interval)
Seizures
Commonest cause disruption of parathyroids post-thyroidectomy
May be temporary or permanent
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Peri-oral and digital parasthesia
Trousseau’s / Chvostek’s sign
Tetany and carpo-pedal spasm
Laryngospasm
ECG changes (prolonged QT interval)
Seizures
Commonest cause disruption of parathyroids post-thyroidectomy
May be temporary or permanent
Consider other causes of hypocalcaemia
Severe Vitamin D deficiency
Hypomagnesaemia
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Acute severe hypocalcaemia (<1.9) with symptoms • Ensure airway stable and cardiac monitor
• 10-20ml 10% calcium gluconate in 50-100 mls 5% dextrose over 1o mins
• Continuous calcium gluconate infusion (100ml 10% in 1 L saline)*
*Infuse initally at 50-100ml per hourTitrate by clinical and biochemical response
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Acute severe hypocalcaemia (<1.9) with symptoms • Ensure airway stable and cardiac monitor
• 10-20ml 10% calcium gluconate in 50-100 mls 5% dextrose over 1o mins
• Continuous calcium gluconate infusion (100ml 10% in 1 L saline)*
On-going management once stabilised• Reversal of underlying cause of hypocalcaemia
• 1-α calcidol 0.25-0.5µg/day
• Sandocal 1000 1 tablet twice daily
• Ensure specialist follow up
*Infuse initally at 50-100ml per hourTitrate by clinical and biochemical response
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� Functional hypoparathyroidism
� Proton pump inhibitors
� Gastro-intestinal loss
� Cytotoxic drugs
� Alcohol
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� Functional hypoparathyroidism
� Proton pump inhibitors
� Gastro-intestinal loss
� Cytotoxic drugs
� Alcohol
Remove cause and give IV MgSo4 24mmol/24 hours
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� 32 year old man
� Thunderclap headache
� Double vision
� 3rd nerve palsy
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� 32 year old man
� Thunderclap headache
� Double vision
� 3rd nerve palsy
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� Na 129 mmol/l
� K 3.8 mmol/l
� Urea 5.6 mmol/l
� Cr 88 μmol/l
� Gl 5.7 mmol/l
� WBC 11.8 x 109/l
� CRP < 5 mg/l
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� Na 129 mmol/l
� K 3.8 mmol/l
� Urea 5.6 mmol/l
� Cr 88 μmol/l
� Gl 5.7 mmol/l
� WBC 11.8 x 109/l
� CRP < 5 mg/l
� LP normal
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sagittal coronal
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sagittal coronal
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sagittal coronal
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sagittal coronal
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� Pituitary apoplexy
� Vascular event within a pituitary tumour
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• Basic resuscitation, analgesia, fluid balance
• Consider cortisol status
• Assess visual fields
• Pituitary hormone screen
• Basic resuscitation, analgesia, fluid balance
• Consider cortisol status
• Assess visual fields
• Pituitary hormone screen
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• Basic resuscitation, analgesia, fluid balance
• Consider cortisol status
• Assess visual fields
• Pituitary hormone screen
• Basic resuscitation, analgesia, fluid balance
• Consider cortisol status
• Assess visual fields
• Pituitary hormone screen
• Check random cortisol (< 100 nmol/L diagnostic)
• If unwell give hydrocortisone 100mg IV
• T4, TSH, Prolactin, IGF-1, LH, FSH, Testo / E2
• Check random cortisol (< 100 nmol/L diagnostic)
• If unwell give hydrocortisone 100mg IV
• T4, TSH, Prolactin, IGF-1, LH, FSH, Testo / E2
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• Basic resuscitation, analgesia, fluid balance
• Consider cortisol status
• Assess visual fields
• Pituitary hormone screen
• Basic resuscitation, analgesia, fluid balance
• Consider cortisol status
• Assess visual fields
• Pituitary hormone screen
• Check random cortisol (< 100 nmol/L diagnostic)
• If unwell give hydrocortisone 100mg IV
• T4, TSH, Prolactin, IGF-1, LH, FSH, Testo / E2
• Check random cortisol (< 100 nmol/L diagnostic)
• If unwell give hydrocortisone 100mg IV
• T4, TSH, Prolactin, IGF-1, LH, FSH, Testo / E2
• Medical stabilisation most important thing
• Conservative management usually sufficient
• Deteriorating vision / reduced GCS may need surgery
• Needs specialist endocrinology / pituitary surgeon
• Medical stabilisation most important thing
• Conservative management usually sufficient
• Deteriorating vision / reduced GCS may need surgery
• Needs specialist endocrinology / pituitary surgeon
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� Consider in all SVT
� High T4, TSH < 0.05
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� Consider in all SVT
� High T4, TSH < 0.05
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� Thyroid storm vanishingly rare
� High output pulmonary oedema (ITU)
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� Thyroid storm vanishingly rare
� High output pulmonary oedema (ITU)
� Agranulocytosis with carbimazole
� Cytopaenias common in hyperthyroidism
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� Consider in hypothermia
� Low T4, TSH > 100
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� Consider in hypothermia
� Low T4, TSH > 100
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� Very high mortality (ITU)
� Supportive treatment
� Thyroxine replacement
� Pericardial effusion
� Adrenal crisis
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� Sodium
� Calcium
� Pituitary
� Thyroid
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