Synopsis
Recognise endocrine physiology causing acute deterioration, start syndrome-directed stabilisation promptly, and avoid correction strategies that create secondary neurological or cardiovascular harm.
- Bedside glucose is the fastest reversible endocrine assessment in any patient with altered behaviour, seizure, focal neurology or reduced consciousness.
- DKA is defined by the combination of hyperglycaemia or known diabetes, ketonaemia and acidosis; glucose alone neither confirms nor grades it.
- HHS produces profound hyperosmolality and dehydration with little significant ketonaemia, so fluid replacement and osmolality trajectory require particular care.
- Suspected adrenal crisis is a clinical treatment decision: draw cortisol if this causes no delay, then give parenteral hydrocortisone and isotonic fluid promptly.
- A sudden headache with visual or ocular-motor abnormality may be pituitary apoplexy; protect cortisol physiology and obtain urgent specialist imaging advice.
- Severe symptomatic hyponatraemia, acute hypocalcaemia and marked hypercalcaemia each demand cause-aware protocols because overly rapid or inappropriate correction can injure.
- Thyroid storm and myxoedema coma are multisystem syndromes rather than laboratory diagnoses; exclude infection, myocardial events, medicines and other precipitants concurrently.
- Repeated observations and biochemical rate of change determine response; reaching a target too rapidly can be as hazardous as failing to improve.
Investigation priorities
Identify hypoglycaemia immediately and establish whether ketonaemia is driving an acute diabetic presentation.
Management branches
An acutely unwell patient may have endocrine or metabolic decompensation.
- Run ABCDE with monitors and intravenous access, check bedside glucose and ketones, and treat hypoglycaemia immediately while confirming response.
- Send blood gas, electrolytes, renal function, calcium and syndrome-specific samples, recording all treatment given before sampling.
- Call senior acute support and activate the current local emergency protocol as soon as DKA, HHS, adrenal crisis, severe electrolyte disturbance or apoplexy is suspected.
Key medicines
HydrocortisoneFor suspected adrenal crisis, give 100 mg intravenously or intramuscularly immediately, followed by the current Society for Endocrinology or local emergency replacement regimen with specialist review.Treatment should not await cortisol results. Monitor glucose, potassium, sodium and fluid status, and plan step-down and mineralocorticoid management with endocrinology once stable.
Intravenous insulin for DKAUse the current JBDS-aligned fixed-rate intravenous insulin infusion based on measured body weight, with fluids, potassium and background basal-insulin decisions specified by the local pathway.Check potassium before and during therapy, add glucose-containing fluid when required to permit ongoing ketone clearance, and never stop solely because capillary glucose normalises.