1.Pituitary crisis
This crisis is a variety of metabolic disorders and organ dysfunctions in hypopituitarism without systematic and regular hormone supplementation treatment, which is one of the life-threatening critical illnesses.
Diagnostic points.
Patients with hypopituitarism, in stressful conditions such as infection, trauma, surgery, etc., develop severe metabolic disorders (hyponatremia, hypoglycemia), psychiatric symptoms (psychosis, confusion, delirium), and coma.
Resuscitation measures.
Mostly caused by hypoglycemia and/or hyponatremia, emphasis is placed on rapid correction of hypoglycemia, water-electrolyte disorders, rapid replenishment of relevant deficient hormones, as well as active control of precipitating factors and management of complications.
Note: The presence of both hypothyroidism and adrenal cortical insufficiency requires supplementation of glucocorticoids before thyroid hormones; otherwise, more serious adrenal crisis can be induced.
2.Thyroid crisis
Abbreviated as hyperthyroid crisis or thyroid storm, it is an acute and extreme exacerbation of hyperthyroidism, often endangering the patient’s life.
Diagnostic points.
Patients with Graves’ disease, thyrotoxic adenoma or multinodular goiter suddenly present with high fever (> 39 ℃), profuse sweating, tachycardia (> 160 beats/min), frequent vomiting and diarrhea, anxiety, tremor, delirium, and coma.
Resuscitation measures.
Rapid inhibition of thyroxine synthesis and secretion (anti-thyroid drugs, iodine), rapid reduction of circulating blood levels of thyroxine (plasma exchange, dialysis), reduction of peripheral tissue response to thyroxine (β2-adrenergic blockers, reserpine or guanethidine), protection of vital organs, prevention of functional failure (antipyretics, glucocorticoids or artificial hibernation).
3, hypothyroidism crisis
Hypothyroid crisis, also known as mucinous edema coma, is a serious clinical condition of hypothyroidism, threatening the life of the patient.
Diagnostic points.
In hypothyroid patients, sudden onset of mental abnormalities (disorientation, confusion, blurred consciousness, drowsy coma), absolute hypothermia (< 30-35 ℃), and markedly reduced thyroid hormone levels.
Note: In severe cases, dyspnea, respiratory distress, respiratory failure, weak respiration, respiratory arrest can occur, which is caused by mucus edema and paralysis of respiratory muscles.
Resuscitation measures.
Rapid supplementation of thyroid hormone and glucocorticoid, warmth and anti-infection.
4.Parathyroid crisis
Including hyperparathyroidism (hyperparathyroidism) caused by hypercalcemia and hypocalcemia caused by hypoparathyroidism.
(1) Hypercalcemia crisis
Diagnosis is based on hyperparathyroidism with high fever, anorexia, vomiting, severe abdominal pain, progressive water loss, polyuria, progressive renal impairment, cardiac arrhythmia, disorientation, confusion, coma, serum calcium > 3.75 mmol/L, increased alkaline phosphatase and parathyroid hormone.
Resuscitation measures.
Strive to lower the blood calcium to 0.7-2.2 mmol/L within 24-48 h. Specific measures are to promote calcium excretion (furosemide, disodium edetate or dialysis), inhibit bone calcium absorption (mitomycin, calcitonin, glucocorticoids), and correct disorders of water-electrolyte acid-base balance (supplementation of saline and potassium, magnesium and phosphorus).
② Hypocalcemia crisis
The main diagnostic points are increased neuromuscular excitability; the characteristic manifestations are episodic paroxysmal hand and foot convulsions, generalized spasms, laryngeal and bronchospasm, convulsions, and seizure-like convulsions in some patients; positive Chvostek’s and Trousscau’s signs; serum calcium < 1. 25 mmol/L.
Resuscitation measures.
Immediately inject calcium and vitamin D; if the convulsions are more than, can add sedative antispasmodic, such as sodium phenytoin, sodium phenobarbital, Valium, and measure blood magnesium, blood phosphorus, low then supplementation.
5.Adrenal crisis
It refers to the clinical symptom group manifested by the sudden underproduction or lack of adrenal cortex caused by various reasons.
Diagnostic points.
Sudden onset of extreme weakness, high fever (> 40 ℃), severe dehydration, oliguria and anuria, tachycardia (> 160 beats/min), cardiac arrhythmia, deficiency shock, vomiting and diarrhea, severe abdominal pain, irritability, and impaired consciousness in patients with severe adrenocortical destruction or chronic hypoadrenocorticism. Laboratory tests: three hypoglycemia (hypoglycemia, hyponatremia, hypocortisol), two hypertension (hyperkalemia, hyperuremic nitrogen) and increased peripheral blood eosinophils (> 0.3 × 10^9 /L).
Resuscitation measures.
Immediate intravenous injection of hydrocortisone, correction of disorders of sugar, water, electrolytes and acid-base balance.
6.Pheochromocytoma crisis
Also known as catecholamine crisis. It is due to the sudden release of large amount of catecholamines into the blood by pheochromocytic tumor, or the sudden decrease or cessation of catecholamine secretion, which causes serious blood pressure and metabolic disorders.
Diagnostic points.
Rapid increase in blood pressure (249-300/180-210 mm Hg) during seizure, alternating hypertension and hypotensive shock; metabolic disorders (elevated blood glucose, decreased glucose tolerance, positive urine glucose); basal metabolic rate increased by more than 40%. Laboratory tests: 24-h urine VMA, catecholamines, elevated plasma free catecholamines, positive colistin test, positive phentolamine block test, tumor detected on imaging.
Resuscitation measures.
Immediate intravenous phentolamine, blood pressure control, blood volume supplementation, symptomatic treatment, elective surgery to remove the tumor.
7.Diabetic crisis
Diabetes mellitus is not diagnosed in time or poorly controlled, and ketoacidosis, hyperosmolar coma and lactic acidosis occur under stressful conditions, i.e. diabetic crisis.
Diagnostic points.
Ketoacidosis is a diabetic patient with increased thirst, polyuria, nausea and vomiting, irritability, impaired consciousness, blood glucose 16. 7-33. 3 mmol /L, elevated blood ketone bodies, strong positive urine ketone bodies, and metabolic acidosis
Hyperosmolar coma: severe dehydration (dry skin, sunken eyes, decreased blood pressure), impaired consciousness, drowsy coma, blood glucose ≥ 33.3 mmol/L, blood Na+ > 145 mmol/L, elevated BUN and Cr, plasma osmolality
Lactic acidosis: impaired consciousness, delirious coma, blood pH < 7. 20, significantly lower blood HCO3-, blood lactate > 5 mmol/L, anion gap > 18 mmol/L.
Resuscitation measures.
Rapid insulin supplementation. Advocate small-dose insulin therapy, that is, the 5 “5” principle: regular insulin 50 U into 500 ml of saline, at a rate of 50 ml per hour, continuous drip, equivalent to 5 U/h, so that blood glucose drops steadily, the general rate of decline is 5 mmol/h; correct the water-electrolyte acid-base balance disorders. Lactic acidosis: etiological treatment, acid correction.
8.Low blood sugar crisis
It is a medical emergency caused by the rapid drop of blood sugar concentration caused by various etiologies, which results in extensive neurological damage.
Diagnostic points.
Patients with risk factors of hypoglycemia suddenly appear symptoms of sympathetic nervous system hyperexcitation (cold sweat, palpitation, hunger, pallor, hand tremor), brain dysfunction (blurred vision, restlessness, disorder of consciousness, seizure, hemiplegia and aphasia, coma), and blood glucose < 2.8 mmol /L.
Resuscitation measures.
Immediate intravenous glucose infusion, mannitol and glucocorticoids if necessary.
9. Hypokalemia crisis
It is a severe decrease in blood potassium caused by various reasons. Diagnostic points: muscle weakness, decreased tendon reflex, blood potassium < 3.5 mmol/L, electrocardiogram shows low T wave and increased U wave.
Resuscitation measures: rapid intravenous potassium supplementation
10.Carcinoid crisis
It is a serious complication of carcinoid syndrome, usually occurs in patients with carcinoid tumors of the foregut and significantly increased urinary secretory histamine (5-H IAA) (>200 mg/d). It can occur spontaneously or be triggered by physical activity, anesthesia, or chemotherapy.
Diagnostic points.
Sudden onset of severe and widespread skin flushing, often lasting hours to days; diarrhea may be markedly worse with abdominal pain; central nervous system symptoms are common, ranging from mild dizziness and vertigo to drowsiness and profound coma; cardiovascular abnormalities are often present, such as tachycardia, cardiac rhythm disturbances, hypertension, or severe hypotension. Blood 5-hydroxytryptamine (5-HT) and urinary 5-H IAA are significantly elevated and excitation tests are positive. Imaging and nuclide imaging may help to detect tumors.
Resuscitation measures.
Tumors found should be actively operated; medical treatment can be applied to growth inhibitors and analogues, serotonin antagonists, etc.