AMLS Endocrine Emergencies 1 — Questions and Answers
Question 1: A 28-year-old type 1 diabetic presents with Kussmaul respirations, fruity breath odor, polyuria, and a blood glucose of 480 mg/dL. Which condition is most likely?
- Hyperosmolar hyperglycemic state (HHS)
- Diabetic ketoacidosis (DKA) (Correct answer)
- Hypoglycemic coma
- Lactic acidosis
Correct answer: Diabetic ketoacidosis (DKA)
DKA classically presents with Kussmaul respirations, fruity (acetone) breath, polyuria, and markedly elevated blood glucose, predominantly in type 1 diabetics due to absolute insulin deficiency and ketone production.
Question 2: A patient with altered mental status has a blood glucose of 38 mg/dL. IV access cannot be established. What is the most appropriate next intervention?
- Oral glucose gel placed in the buccal mucosa
- Intramuscular glucagon 1 mg (Correct answer)
- Intranasal dextrose spray
- Subcutaneous insulin to stabilize glucose
Correct answer: Intramuscular glucagon 1 mg
When IV access is unavailable in a hypoglycemic patient with altered mental status (making oral glucose unsafe), IM glucagon stimulates hepatic glycogenolysis to raise blood glucose.
Question 3: Which laboratory finding best differentiates diabetic ketoacidosis (DKA) from hyperosmolar hyperglycemic state (HHS)?
- Serum glucose above 600 mg/dL
- Serum osmolality greater than 320 mOsm/kg
- Presence of significant ketonemia and metabolic acidosis (Correct answer)
- Elevated BUN and creatinine
Correct answer: Presence of significant ketonemia and metabolic acidosis
DKA is characterized by significant ketonemia and anion-gap metabolic acidosis, whereas HHS features extreme hyperglycemia and hyperosmolality without significant ketosis or acidosis.
Question 4: A 55-year-old patient on long-term corticosteroids presents with hypotension, weakness, nausea, and hypoglycemia after abruptly stopping their medication. Which condition is most likely?
- Cushing's syndrome exacerbation
- Addisonian (adrenal) crisis (Correct answer)
- Thyroid storm
- Pheochromocytoma
Correct answer: Addisonian (adrenal) crisis
Adrenal crisis occurs when exogenous corticosteroids are abruptly withdrawn, causing acute adrenal insufficiency with hypotension, weakness, nausea, vomiting, and hypoglycemia due to loss of cortisol and aldosterone.
Question 5: A patient presents with fever of 104°F, tachycardia (HR 148), atrial fibrillation, agitation, and exophthalmos. Which endocrine emergency should be suspected?
- Myxedema coma
- Adrenal crisis
- Thyroid storm (thyrotoxic crisis) (Correct answer)
- Hyperosmolar hyperglycemic state
Correct answer: Thyroid storm (thyrotoxic crisis)
Thyroid storm presents with hyperpyrexia, extreme tachycardia, dysrhythmias (especially atrial fibrillation), agitation, and signs of hyperthyroidism such as exophthalmos, reflecting life-threatening excess thyroid hormone activity.
Question 6: What is the initial priority in managing a patient in hyperosmolar hyperglycemic state (HHS) with a serum osmolality of 345 mOsm/kg and blood glucose of 820 mg/dL?
- Aggressive IV insulin bolus
- Sodium bicarbonate infusion
- Aggressive IV fluid resuscitation with isotonic saline (Correct answer)
- Immediate hemodialysis
Correct answer: Aggressive IV fluid resuscitation with isotonic saline
The cornerstone of HHS management is aggressive IV fluid resuscitation with isotonic saline to correct profound dehydration and hyperosmolality before insulin administration, which can precipitate cerebral edema if given first.
Question 7: A patient with known hypothyroidism presents unresponsive with bradycardia, hypothermia (temp 92°F), hypoventilation, and hypotension. Which condition does this presentation indicate?
- Thyroid storm
- Addisonian crisis
- Myxedema coma (Correct answer)
- Hypoglycemic coma
Correct answer: Myxedema coma
Myxedema coma is a life-threatening complication of severe hypothyroidism characterized by altered mental status, hypothermia, bradycardia, hypoventilation, and hypotension, often triggered by infection or medication non-compliance.
AMLS Endocrine Emergencies 1
A 28-year-old type 1 diabetic presents with Kussmaul respirations, fruity breath odor, polyuria, and a blood glucose of 480 mg/dL.
Which condition is most likely?