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A practical guide to the management of medical emergencies - part 8

Rối loạn tuyến yên / vùng dưới đồi: • hoại tử tuyến yên sau sinh (hội chứng Sheehan) • hoại tử hoặc chảy máu vào một macroadenoma yên • Trụ chấn thương (thường liên quan với đái tháo nhạt) • Nhiễm trùng huyết hoặc căng thẳng phẫu thuật ở bệnh nhân bị suy tuyến yên | CHAPTER 72 459 Pituitary hypothalamic disorders Postpartum pituitary necrosis Sheehan syndrome Necrosis or bleeding into a pituitary macroadenoma Head trauma often associated with diabetes insipidus Sepsis or surgical stress in patients with hypopituitarism TABLE 72.3 Urgent investigation in suspected acute adrenal insufficiency Blood glucose Sodium potassium and creatinine Plasma cortisol and corticotropin 10 ml blood in a heparinized tube for later analysis Full blood count Coagulation screen Erythrocyte sedimentation rate and C-reactive protein Blood culture Urine stick test microscopy and culture Chest X-ray ECG Typical biochemical findings In acute adrenal Insufficiency Raised creatinine Low sodium 120-130mmol L Raised potassium 5-7mmol L Low glucose Eosinophilia lymphocytosis A plasma cortisol level of 700nmol L in a critically ill patient effectively excludes adrenal insufficiency. Corticotropin is high in primary and low in secondary adrenal insufficiency. Q nj ệ 0 p TJ 0 460 SPECIFIC PROBLEMS ENDOCRINE METABOLIC TABLE 72.4 Management of suspected acute adrenal insufficiency Action Comment Investigation Take blood for measurement of cortisol and corticotropin levels for later analysis and other investigations Table 72.3 Exclude treat hypoglycemia Check blood glucose if 3.5 mmol L give 50 ml of 50 glucose IV via a large vein Fluid replacement 1 L of normal saline over 30min then 1 L of normal saline over 60min If systolic BP remains 90 mmHg after 2 L saline put in a central line and infuse saline to keep the central venous pressure 5-10cmH2O If systolic BP is 90 mmHg give normal saline 1 L every 6-8h IV until the fluid deficit has been corrected as judged by clinical improvement and the absence of postural hypotension Hyperkalemia is common in acute adrenal insufficiency and potassium should not be added if plasma potassium is 5 mmol L Steroid replacement Give hydrocortisone 100mg IV followed by a continuous infusion of 10mg h over the first 24 h Continue .