A 27 year old female, unwell requiring simultaneous assessment and management of her immediate life threats.
Answers:
1. Describe the abnormalities
Normal pH
low HCO3 and BE
CO2 28.4 (expected 32 +/- 2), in setting of likely VBG
Anion Gap = 11 (normal)
===> Compensated normal anion gap metabolic acidosis
hyponatraemia (corrected = 130)
hyperkalaemia
severe hypocalcaemia
high glucose (no ketones given, normal anion gap)
Low pO2 – venous sample
2. Interpret your findings
(a) Biochemical features consistent with multiple endocrine dysfunction:
Addison’s disease (low Na, high K, NAGMA)
Uncontrolled Diabetes (check ketones)
Hypocalcaemia
Check Thyroid function ( very fast HR)
(b) Features of Sepsis:
hypotension, tachycardia, fever and features on history suggestive, lactate is normal
3. Examination Features:
(a) Source of infection – thorough head to toe examination, including ENT, chest, abdomen. CXR and UA immediately
(b) Severity of sepsis/ complications – GCS, perfusion, UO, Ileus,
(c) Features of Addison’s – weight loss, hyperpigmentation
In general, some features of Addison’s include:
- Muscle weakness and fatigue
- Weight loss and decreased appetite
- Darkening of your skin (hyperpigmentation)
- Low blood pressure, even fainting
- Salt craving
- Low blood sugar (hypoglycemia)
- Nausea, diarrhea or vomiting
- Muscle or joint pains
- Irritability
- Depression
- Body hair loss or sexual dysfunction in women
(d) Features of hypocalcaemia
“CATS go numb”- Convulsions, Arrhythmias, Tetany and numbness/parasthesias in hands, feet, around mouth and lips.
- Petechiae, purpura
- Oral, perioral and acral paraesthesia (early symptom)
- Carpopedal and generalized tetany
- Latent tetany
- Trousseau’s sign
- Chvostek’s sign
- Tendon reflexes are hyperactive
- Life-threatening complications
- Laryngospasm, brochospasm
- Cardiac arrhythmias
- Effects on cardiac output
- Positive chronotropy
- Negative inotropy effect
- ECG – Intermittent QT prolongation – high risk of TdP
Chronic hypocalcaemia – poor dentition, cataracts, papilloedema, ectopic calcification, dementia
(e) Complications of Diabetes:
Retinopathy
Neuropathy
Renal impairment….. etc
4. Treatment Priorities
Full cardiac monitoring, serial ECG’s, defib pads applied
Resuscitation – as per surviving sepsis – fluids, antibiotics (source control), other – inotropes, monitor response to treatment
Replace Calcium – 10 mls of 10% Ca Gluconate iv
Steroids – hydrocortisone 200 mg ivi/ Dexamethasone
Insulin Infusion (2-4 units/hr)- aim to correct ketoacidosis if present and correct glucose gradually over 2-4 hours