Endocrine and metabolic emergencies

Recognise and treat the endocrine emergencies seen in Indian ICUs: DKA (including euglycaemic DKA with SGLT2 inhibitors), HHS, adrenal crisis, thyroid storm and myxoedema coma, plus ICU glucose targets and hypoglycaemia.

6 topics

01
Diabetic ketoacidosis (including euglycaemic DKA)
DKA = diabetes or glucose ≥ 200 mg/dL + β-hydroxybutyrate ≥ 3.0 mmol/L (or urine ketones ≥ 2+) + pH < 7.3 and/or HCO3- < 18. Treat with fluids, fixed-rate insulin 0.1 units/kg/h once K+ ≥ 3.5, potassium replacement, and dextrose once glucose < 250 mg/dL until ketones clear.
7 stepsAlgorithm2 dosesNew
02
Hyperosmolar hyperglycaemic state (HHS)
HHS = glucose ≥ 600 mg/dL, effective osmolality > 300 mOsm/kg, minimal ketosis and no significant acidosis. Rehydrate first and slowly; fall in osmolality 3-8 mOsm/kg/h and in Na+ ≤ 10 mmol/L/24 h; low-dose insulin 0.05 units/kg/h once glucose stops falling with fluid alone.
5 stepsAlgorithm1 dosesNew
03
Adrenal crisis
Unexplained shock, vomiting, hyponatraemia, hyperkalaemia or hypoglycaemia in someone at risk (steroid use, Addison's, pituitary disease): give hydrocortisone 100 mg IV immediately after a random cortisol, without waiting for results, plus 1 L isotonic fluid in the first hour.
5 stepsAlgorithm1 dosesNew
04
Thyroid storm and myxoedema coma
Thyroid storm: Burch-Wartofsky score ≥ 45 → β-blocker, thionamide (PTU preferred), iodine ≥ 1 h later, hydrocortisone, cooling and treatment of the trigger. Myxoedema coma: supportive care, hydrocortisone first, then thyroxine.
7 stepsAlgorithm3 dosesNew
05
Glucose control in the ICU
Start an insulin protocol when glucose is persistently ≥ 180 mg/dL, titrate to 140-200 mg/dL (not 80-139), monitor at least hourly while unstable, and treat hypoglycaemia immediately.
5 stepsAlgorithmNew
06
Hypoglycaemia
Glucose < 70 mg/dL (level 1), < 54 mg/dL (level 2) or any value with cognitive impairment needing help (level 3). Give 15-25 g IV dextrose or IM glucagon, recheck at 15 min, then find and treat the cause; sulphonylurea overdose needs prolonged dextrose ± octreotide.
5 stepsAlgorithm1 dosesNew

Drugs in this module

Doses written for this module's context. The same drug may read differently in another module.

Regular (soluble) insulin infusion

Insulin

Indications: DKA, HHS, ICU hyperglycaemia, hyperkalaemia.
Adult dose: DKA: fixed rate 0.1 units/kg/h (optional 0.1 units/kg bolus). HHS: 0.05 units/kg/h once glucose stops falling with fluids alone. ICU hyperglycaemia: protocol-driven to 140-180 mg/dL.
Preparation (India): 50 units in 50 mL 0.9% saline (1 unit/mL). Check vial strength: U-40 (40 units/mL) or U-100.
Cautions: Hypokalaemia (do not start if K+ < 3.5 mmol/L), hypoglycaemia, hypophosphataemia.

Hydrocortisone

Glucocorticoid (with mineralocorticoid activity at high dose)

Indications: Adrenal crisis; thyroid storm; myxoedema coma (until adrenal insufficiency excluded); septic shock.
Adult dose: Adrenal crisis: 100 mg IV bolus, then 200 mg/24 h (continuous or 50 mg every 6 h); taper over 1-3 days once stable. Thyroid storm: 300 mg IV load then 100 mg every 8 h.
Preparation (India): Hydrocortisone sodium succinate 100 mg vials.
Cautions: Hyperglycaemia, hypernatraemia; fludrocortisone not needed while hydrocortisone > 50 mg/day.

Propylthiouracil (PTU)

Thionamide

Indications: Thyroid storm (preferred: also blocks T4→T3 conversion); first-trimester pregnancy.
Adult dose: 500-1000 mg loading dose orally/NG, then 250 mg every 4 h.
Cautions: Hepatotoxicity, agranulocytosis. Methimazole 60-80 mg/day is the alternative.

Propranolol

Non-selective β-blocker

Indications: Thyroid storm; thyrotoxic periodic paralysis.
Adult dose: 60-80 mg orally/NG every 4 h; IV 1 mg slowly, repeat. Esmolol infusion if unstable or asthma.
Cautions: Thyrotoxic cardiomyopathy with low output: use esmolol cautiously with echo guidance.

Levothyroxine

Thyroid hormone

Indications: Myxoedema coma.
Adult dose: IV 200-400 mcg load, then 1.6 mcg/kg/day (IV dose ≈ 75% of oral); lower doses in elderly/cardiac disease.
Preparation (India): Tablets (NG) widely available; IV vials limited.
Cautions: Precipitates myocardial ischaemia and arrhythmias; give hydrocortisone first.

Dextrose (glucose)

Carbohydrate

Indications: Hypoglycaemia; with insulin in DKA once glucose < 250 mg/dL; hyperkalaemia.
Adult dose: Hypoglycaemia: 15-25 g IV (e.g. 150-200 mL 10% or 50 mL 25% dextrose / 50 mL 50% via large vein), recheck at 15 min.
Preparation (India): 5%, 10%, 25% (25 mL ampoules) and 50% available.
Cautions: 50% is sclerosant: use a large vein and flush.

Potassium chloride

Electrolyte

Indications: Potassium replacement during DKA/HHS treatment.
Adult dose: K+ < 3.5: 10 mmol/h IV before insulin. K+ 3.5-5.0: 20-30 mmol per litre of IV fluid to keep K+ 4-5 mmol/L.
Preparation (India): 15% KCl 10 mL ampoule = 20 mmol; premixed bags preferred.
Cautions: Never as an undiluted bolus; reduce in oliguria.

Sodium bicarbonate

Alkalinising agent

Indications: DKA with pH < 7.0 only.
Adult dose: 100 mmol (100 mL 8.4%) in 400 mL sterile water over 2 h; repeat until pH > 7.0.
Cautions: Hypokalaemia, paradoxical CSF acidosis, cerebral oedema risk in children.

6 topics

Diabetic ketoacidosis (including euglycaemic DKA)

Hyperosmolar hyperglycaemic state (HHS)

Adrenal crisis

Thyroid storm and myxoedema coma

Glucose control in the ICU

Hypoglycaemia

Drugs in this module

Module references (9)