| 🍬 Diabetic Ketoacidosis |
- Polyuria, polydipsia, weight loss and dehydration.
- Nausea, vomiting and abdominal pain.
- Kussmaul breathing and ketotic/fruity breath.
- Confusion, drowsiness or coma in severe cases.
- Usually type 1 diabetes, but can occur in type 2 diabetes, especially with illness or SGLT2 inhibitors.
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- Blood glucose usually >11 mmol/L, but euglycaemic DKA can occur.
- Blood ketones usually ≥3 mmol/L.
- Venous pH <7.3 and/or bicarbonate <15 mmol/L.
- U&E, potassium, creatinine, osmolality, infection screen and ECG.
- Identify trigger: missed insulin, infection, MI, pregnancy, steroid/SGLT2 inhibitor use.
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- Manage using local JBDS DKA pathway.
- IV 0.9% sodium chloride for rehydration.
- Fixed-rate IV insulin infusion to stop ketogenesis.
- Continue long-acting basal insulin if already prescribed, unless local pathway advises otherwise.
- Potassium replacement guided by serum potassium; total body potassium is depleted even if initial K⁺ is high.
- Add IV glucose once blood glucose falls, while continuing insulin until ketones clear/acidosis resolves.
- Hourly glucose/ketones and frequent U&E/VBG monitoring.
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| 💧 Hyperosmolar Hyperglycaemic State |
- Severe dehydration, thirst, weakness and weight loss.
- Altered mental state, confusion, seizures or coma.
- Usually older adults with type 2 diabetes.
- Often triggered by infection, MI, stroke, steroids, poor intake or dehydration.
- Ketosis absent or mild; acidosis not the main feature.
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- Marked hyperglycaemia, often ≥30 mmol/L.
- High serum osmolality, commonly ≥320 mOsm/kg.
- Minimal ketones and pH usually >7.3.
- U&E, creatinine, VBG, lactate, infection screen, ECG.
- Assess corrected sodium and rate of osmolality fall.
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- Manage using local JBDS HHS pathway.
- Careful IV fluid replacement, usually 0.9% sodium chloride initially.
- Avoid rapid osmolality shifts; aim for gradual correction.
- Insulin is often delayed until fluids have started lowering glucose, unless significant ketonaemia is present.
- Potassium and electrolyte monitoring.
- VTE prophylaxis unless contraindicated.
- Treat precipitating illness, e.g. infection, MI or stroke.
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| 🔥 Thyroid Storm |
- Severe thyrotoxicosis with fever, agitation, delirium or coma.
- Tachycardia, atrial fibrillation, heart failure or shock.
- Diarrhoea, vomiting, jaundice or abdominal pain may occur.
- Triggers: infection, surgery, trauma, childbirth, radioiodine, iodine load or stopping antithyroid medication.
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- Clinical diagnosis - do not wait for TFTs if unstable.
- TSH suppressed, free T4/T3 elevated.
- FBC, U&E, LFT, calcium, glucose, cultures if infection suspected.
- ECG for AF/tachyarrhythmia.
- Consider Burch-Wartofsky score if locally used.
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- Urgent endocrine/ICU input.
- Beta-blocker for adrenergic symptoms, if no contraindication.
- Antithyroid drug: carbimazole/methimazole or propylthiouracil according to local specialist advice.
- Iodine solution may be used after antithyroid drug under specialist guidance.
- IV hydrocortisone.
- Supportive care: cooling, fluids, oxygen, treat infection/trigger.
- Avoid aspirin for fever because it may increase free thyroid hormone; use paracetamol if appropriate.
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| ❄️ Myxoedema Coma |
- Severe hypothyroidism with reduced consciousness.
- Hypothermia, bradycardia, hypotension and hypoventilation.
- Hyponatraemia, hypoglycaemia, ileus, seizures or effusions may occur.
- Often older patients; triggers include infection, cold exposure, MI, stroke, sedatives or stopping levothyroxine.
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- TSH usually high and free T4 low in primary hypothyroidism.
- U&E: hyponatraemia common.
- Glucose, cortisol, CK, ABG/VBG, ECG.
- CXR/cultures if infection suspected.
- Do not delay treatment if strongly suspected.
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- ICU-level care and endocrine input.
- IV levothyroxine under specialist guidance; liothyronine may be considered in selected severe cases.
- IV hydrocortisone before or with thyroid hormone until adrenal insufficiency excluded.
- Passive warming; avoid aggressive rewarming.
- Treat hypoglycaemia, hyponatraemia, hypoventilation and precipitating infection/illness.
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| 🧂 Adrenal Crisis |
- Severe weakness, vomiting, abdominal pain, confusion or collapse.
- Hypotension, shock or dehydration.
- Hypoglycaemia, especially in children.
- Primary adrenal failure may cause hyperpigmentation, hyponatraemia and hyperkalaemia.
- Risk: known Addison’s disease, pituitary disease, long-term steroids, abrupt steroid withdrawal, sepsis or surgery.
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- Clinical diagnosis - treatment must not wait.
- U&E: hyponatraemia, hyperkalaemia, AKI.
- Glucose: hypoglycaemia may occur.
- Cortisol/ACTH can be taken if immediately possible, but do not delay hydrocortisone.
- Infection/sepsis screen if trigger suspected.
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- Immediate hydrocortisone 100 mg IV or IM.
- Rapid IV 0.9% sodium chloride; add glucose if hypoglycaemic.
- Continue hydrocortisone replacement as infusion or regular IV/IM dosing according to local endocrine pathway.
- Treat trigger, e.g. infection, vomiting, trauma or missed steroids.
- Monitor BP, glucose, sodium, potassium and urine output.
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| ⚡ Phaeochromocytoma Crisis |
- Severe episodic or sustained hypertension.
- Headache, sweating, palpitations, tremor, pallor and anxiety.
- May cause hypertensive emergency, arrhythmia, MI, stroke, pulmonary oedema or shock.
- Triggers: surgery, anaesthesia, childbirth, trauma, steroids, metoclopramide, some antidepressants or tumour manipulation.
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- Clinical emergency if hypertensive crisis/end-organ damage.
- Plasma free metanephrines or urinary metanephrines once stable.
- ECG, troponin, renal function, glucose, lactate where indicated.
- CT/MRI adrenal/abdomen after biochemical confirmation where possible.
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- Urgent endocrine/ICU input.
- Alpha-blockade first; never give beta-blocker before adequate alpha-blockade.
- IV antihypertensive therapy may be needed in crisis under specialist/ICU guidance.
- Careful IV fluids after alpha-blockade because chronic vasoconstriction causes volume contraction.
- Definitive treatment is surgical resection after stabilisation and preparation.
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| 🍭 Hypoglycaemia |
- Sweating, tremor, hunger, palpitations and anxiety.
- Confusion, behavioural change, seizures, reduced consciousness or coma.
- Common with insulin or sulfonylureas, missed meals, alcohol, renal failure or exercise.
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- Check capillary blood glucose immediately.
- In hospital diabetes care, treat glucose <4 mmol/L: “4 is the floor”.
- If unexplained/recurrent: consider insulin, C-peptide, sulfonylurea screen, cortisol, renal/liver function.
- Do not delay treatment while investigating.
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- If conscious and safe swallow: give fast-acting carbohydrate, then longer-acting carbohydrate if next meal not due.
- If unable to swallow/unconscious: IV glucose or IM glucagon if IV access unavailable.
- Recheck glucose after 10–15 minutes and repeat treatment if still low.
- Identify cause and adjust insulin/sulfonylurea plan.
- Observe longer after long-acting insulin or sulfonylurea because recurrence is common.
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| 🧂 Severe Hypercalcaemia |
- “Stones, bones, groans and psychiatric overtones”.
- Thirst, polyuria, dehydration, constipation, abdominal pain.
- Confusion, drowsiness, weakness or coma.
- Causes: malignancy, primary hyperparathyroidism, vitamin D excess, granulomatous disease.
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- Corrected calcium or ionised calcium.
- U&E/creatinine, phosphate, magnesium.
- PTH to distinguish PTH-mediated from non-PTH causes.
- Vitamin D, myeloma screen or malignancy work-up depending on context.
- ECG: short QT interval may occur.
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- IV 0.9% sodium chloride rehydration if dehydrated, with caution in heart/renal failure.
- Stop calcium/vitamin D supplements and thiazides if appropriate.
- IV bisphosphonate after rehydration if severe/symptomatic or malignancy-related, guided by local policy.
- Calcitonin may be used for rapid short-term effect in severe cases under specialist advice.
- Treat underlying cause and involve endocrine/oncology if severe.
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| 🧊 Severe Hyponatraemia / SIADH-related Emergency |
- Nausea, headache, confusion, seizures or coma.
- Risk is higher when sodium falls rapidly.
- Causes: SIADH, adrenal insufficiency, diuretics, polydipsia, heart/liver/renal failure.
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- Serum sodium and osmolality.
- Urine osmolality and urine sodium.
- Glucose, cortisol, TSH, U&E, fluid status assessment.
- Medication review.
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- Seizures/coma/severe symptoms: urgent senior/endocrine/ICU advice and hypertonic saline according to local protocol.
- Avoid overly rapid correction to reduce risk of osmotic demyelination.
- Treat underlying cause: adrenal crisis, drugs, SIADH trigger, volume depletion.
- Monitor sodium frequently during correction.
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| 📈 Hyperaldosteronism with Severe Hypertension / Hypokalaemia |
- Severe or resistant hypertension.
- Hypokalaemia causing weakness, cramps, palpitations or arrhythmia.
- May be due to adrenal adenoma or bilateral adrenal hyperplasia.
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- U&E: hypokalaemia and metabolic alkalosis may occur.
- Plasma aldosterone-renin ratio after correcting potassium and considering medication effects.
- ECG if significant hypokalaemia.
- Adrenal imaging after biochemical confirmation.
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- Treat hypertensive emergency if end-organ damage using acute medical protocols.
- Correct potassium and magnesium.
- Mineralocorticoid receptor antagonist such as spironolactone/eplerenone under specialist guidance.
- Adrenalectomy may be considered for unilateral aldosterone-producing adenoma after specialist work-up.
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