Diabetes and Endocrinology

Adult conditions

Hypertension

• Hypertensive emergency (BP>220/120)
• Severe hypertension (systolic BP >180) with any of the following concerning features:
  • headache
  • confusion
  • blurred vision
  • retinal haemorrhage
  • reduced level of consciousness
  • seizures
  • proteinuria
  • papilledema
  • signs of heart failure
  • chest pain
  • acute kidney injury
• If suspected pregnancy induced hypertension or pre-eclampsia refer patient to the emergency department or maternity assessment unit of a facility that offers obstetric services where possible.
• Phaeochromocytoma in crisis with uncontrolled hypertension

Diabetes mellitus

• Diabetes-related ketoacidosis
• Diabetes and severe vomiting
• Acute severe hyperglycaemia
• Acute severe hypoglycaemia
• Hyperosmolar hyperglycaemic state (HHS)
• Foot ulcer with infection and systemically unwell or febrile
• Invasive infection or rapidly spreading cellulitis of the foot (defined by peripheral redness around the wound >2cm)
• Acute foot ischaemia
• Wet gangrene foot
• Newly diagnosed type 1 diabetes, please contact the on-call registrar or consultant immediately. The client should be referred to a diabetes specialist service within 24 hours. If a specialist service is not available, the client should present to the nearest emergency department.

High Risk Foot

• Foot ulcer with infection and systemically unwell or febrile
• Invasive infection or rapidly spreading cellulitis (defined by peripheral redness around the wound >2cm)
• Acute ischaemia
• Wet gangrene
• Acute or suspected acute Charcot foot unless able to access a High Risk Foot clinic within 48hours.

Hyperthyroidism

• Hyperthyroidism complicated by cardiac, respiratory compromise or other indications of severe illness (fever, vomiting, labile blood pressure, altered mental state)
• Neutropenic sepsis in patient taking carbimazole or propylthiouracil
• Hyperthyroidism with hypokalaemia or paralysis
• Suspected myxoedema coma (altered consciousness, hypothermia, fluid overload, bradycardia, hyponatraemia)

Insulinoma / hypoglycaemia unrelated to diabetes

• Severe hypoglycaemia

Obesity

• Acute decompensation of cardiorespiratory/ renal function

Adrenal disease

• Addisonian crisis
• Suspected or confirmed acute adrenal insufficiency

Adrenal Mass

• Severe hypertension (see above)
• Phaeochromocytoma crisis
• Potassium <3mmol/L
• Suspected adrenal haemorrhage

Pituitary disorders

• Pituitary tumour with sudden severe headache
• Acute onset visual loss or diplopia
• Pituitary tumour with likely adrenal crisis (hypotension, tachycardia, vomiting, altered level of consciousness)

Thyroid enlargement / thyroid nodules

• Stridor associated with a thyroid mass
• Possible tracheal or superior vena cava obstruction from retrosternal thyroid enlargement

Oligo/amenorrhoea, hirsutism, acne, female infertility

• Pituitary tumour with sudden severe headache, acute onset visual loss/diplopia or adrenal crisis (hypotension, tachycardia, vomiting, altered level of consciousness)

Calcium, electrolyte and metabolic bone disorders

• Hypokalaemia with potassium <3mmol/L
• Acutely symptomatic hypocalcaemia (e.g. tetany) with serum corrected calcium <2.0mmol/L
• Severe symptomatic hypercalcaemia (usually serum calcium > 3.0 mmol/l)
• Hypernatraemia or hyponatraemia with acute confusion/delirium
• Suspected or confirmed arginine vasopressin deficiency (previously known as central diabetes insipidus) or arginine vasopressin resistance (previously known as nephrogenic diabetes insipidus)  with hypernatraemia

Paediatric Conditions

Paediatric obesity

• New diagnosis of type 1 diabetes = polyuria and/or polydipsia and random BSL >11.0.
• Ketoacidosis in a person known to have diabetes with any of the following:
  • systemic symptoms (fever, lethargy) or
  • vomiting or
  • inability to eat (even if not vomiting) or
  • abdominal pain or
  • headache

Paediatric diabetes

• New diagnosis of type 1 diabetes = polyuria and/or polydipsia and random BSL >11.0.
• Ketoacidosis in a known diabetic with any of the following:
  • systemic symptoms (fever, lethargy) or
  • vomiting or
  • inability to eat (even if not vomiting) or
  • abdominal pain or
  • headache

Growth failure

• Suspected pituitary mass (visual field loss/CNS signs)
• Addisonian crisis (including unexplained hyponatraemia & hypoglycaemia)
• Myxoedema coma
• New onset diabetes insipidus (including unexplained hypernatraemia)
• Hypocalcaemia (including acute rickets) with seizures