CPEN Endocrine and Metabolic Emergencies — Questions and Answers
Question 1: A 12-year-old presents with polyuria, polydipsia, weight loss, and fruity breath. Blood glucose is 530 mg/dL, pH 7.16, and bicarbonate 9 mEq/L. After establishing IV access, what is the priority first intervention?
- Administer an IV insulin bolus immediately
- Begin IV fluid resuscitation with isotonic saline (Correct answer)
- Administer IV sodium bicarbonate to correct the acidosis
- Recheck capillary glucose and reassess in 30 minutes
Correct answer: Begin IV fluid resuscitation with isotonic saline
In pediatric DKA, isotonic fluid resuscitation must precede insulin therapy. Administering insulin before adequate hydration risks worsening hypokalemia and hemodynamic instability. Sodium bicarbonate is not recommended in pediatric DKA due to risks of paradoxical CNS acidosis and cerebral edema. Insulin infusion begins only after fluids are running.
Question 2: A 3-week-old infant presents with prolonged jaundice, poor feeding, hypotonia, and a bulging anterior fontanelle. TSH is elevated at >150 mIU/L and free T4 is undetectable. What is the diagnosis?
- Neonatal sepsis
- Congenital hypothyroidism (Correct answer)
- Neonatal hypocalcemia
- Inborn error of metabolism
Correct answer: Congenital hypothyroidism
Congenital hypothyroidism presents with prolonged jaundice, large fontanelles, poor feeding, hypotonia, and constipation. An extremely elevated TSH with undetectable T4 confirms the diagnosis. Early levothyroxine treatment is critical to prevent irreversible intellectual disability. This condition is targeted by newborn screening (heel-stick), but some infants present clinically before results return.
Question 3: A 6-year-old with type 1 diabetes is found unresponsive with a blood glucose of 24 mg/dL. IV access cannot be established. What is the most appropriate intervention?
- Apply oral glucose gel to the buccal mucosa
- Administer glucagon intramuscularly or intranasally (Correct answer)
- Insert an intraosseous line and infuse 10% dextrose
- Perform rectal glucose administration
Correct answer: Administer glucagon intramuscularly or intranasally
For severe hypoglycemia with altered consciousness when IV access is unavailable, glucagon (IM or intranasal) is the priority intervention. It stimulates hepatic glycogenolysis to raise blood glucose rapidly. Oral glucose gel is contraindicated in an unresponsive child due to aspiration risk. IO dextrose is a valid alternative but requires more setup time than glucagon IM/IN.
Question 4: A 14-year-old with known Addison's disease presents with severe weakness, hypotension unresponsive to IV fluid boluses, vomiting, and sodium of 126 mEq/L. She reports running out of her medications one week ago. What is the priority treatment?
- Start IV norepinephrine infusion for refractory hypotension
- Administer IV hydrocortisone immediately (Correct answer)
- Give oral fludrocortisone and monitor
- Administer IV calcium gluconate for electrolyte correction
Correct answer: Administer IV hydrocortisone immediately
Acute adrenal crisis (Addisonian crisis) is life-threatening adrenocortical failure presenting with fluid-refractory hypotension, hyponatremia, and hyperkalemia. IV hydrocortisone (stress-dose steroids) is the definitive treatment and must not be delayed. Vasopressors are adjunctive but will not reverse the crisis without steroid replacement. This patient's missed medications precipitated the crisis.
Question 5: A 7-year-old with a history of craniopharyngioma resection presents with urine output of 9 mL/kg/hr, extreme thirst, urine specific gravity of 1.001, and serum sodium of 160 mEq/L. What is the most likely diagnosis?
- Type 1 diabetes mellitus
- Diabetes insipidus (Correct answer)
- Syndrome of inappropriate antidiuretic hormone (SIADH)
- Psychogenic polydipsia
Correct answer: Diabetes insipidus
Diabetes insipidus (DI) results from deficiency of antidiuretic hormone (ADH), commonly occurring after cranial surgery or trauma. It presents with massive polyuria of very dilute urine (specific gravity ≤1.005), polydipsia, and hypernatremia. It differs from DM in that blood glucose is normal and there is no glycosuria. Treatment is desmopressin (DDAVP).
Question 6: A 10-year-old presents with palpitations, heat intolerance, weight loss despite increased appetite, exophthalmos, and a visible neck mass. For which acute complication should the emergency nurse be alert?
- Severe hypoglycemia
- Thyroid storm (thyrotoxic crisis) (Correct answer)
- Acute adrenal crisis
- Hypercalcemic crisis
Correct answer: Thyroid storm (thyrotoxic crisis)
This presentation is classic for Graves' disease (hyperthyroidism). Thyroid storm is a life-threatening decompensation characterized by hyperthermia (>40°C), severe tachycardia, hypertension, vomiting, and altered mental status — often triggered by illness or missed doses. Treatment requires beta-blockers, thionamides (PTU/methimazole), iodine solution, and corticosteroids given in sequence.
CPEN Endocrine and Metabolic Emergencies
A 12-year-old presents with polyuria, polydipsia, weight loss, and fruity breath.
Blood glucose is 530 mg/dL, pH 7.16, and bicarbonate 9 mEq/L.
After establishing IV access, what is the priority first intervention?