Hepatic Failure/GI/Endocrine Emergencies
For patients on aspirin for secondary cardiovascular prevention who present with GI bleed, holding
aspirin therapy is not recommended. If aspirin is interrupted, it should be resumed within 24 hours
of achieving hemostasis.
Timing of reinitiation of other antiplatelet therapy depends on the risk of rebleed determined during
endoscopy. If this risk is considered low, P2Y12 receptor blockers may be restarted within 1β3 days
after hemostasis. Reinitiation of these agents is further delayed in high-risk patients until the risk
has decreased.
Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) are the most common
diabetic emergencies.
DKA accounts for 500,000 hospital days and costs up to $5 billion per year in the United States.
Between 2009 and 2014, there was a 54% increase in hospitalization rates for DKA in the United
States, with the highest rates in patients younger than 44.
Most patients who develop DKA have type 1 diabetes, and DKA is considered the most important
contributor to mortality rates in children and adolescents with diabetes.
| d. | In-hospital mortality rates for DKA are 0.2%β1.4%, and can be as high as 5%β20% for HHS, |
|---|
depending on age and other comorbidities.
prevalence rates depending on the level of hyperglycemia and patient population evaluated.
About 27% of critically ill patients have a BG above 200 mg/dL on ICU admission, and about 90%
of patients will have at least one BG reading above 110 mg/dL during their ICU stay.
Hyperglycemia has consistently been associated with increased mortality in critically ill patients,
most notably in patients without diabetes. The link between hyperglycemia and worse outcomes
seems strongest for patients with acute coronary syndrome or stroke.
Glucose variability (BG fluctuation over time) has also been associated with ICU mortality.
Hypoglycemia also occurs commonly in the ICU, both with and without intensive glucose control.
In a large international cohort of patients, moderate hypoglycemia (BG less than 70 mg/dL)
occurred in 37% of patients and was independently associated with mortality on multivariable
regression (OR 1.78; 95% CI, 1.39β2.27).
Glucose Algorithm Regulation (NICE-SUGAR) study, moderate hypoglycemia occurred in 45%
of patients (74.2% in the intensive-control group and 15.8% in the conventional-control group), and
severe hypoglycemia (BG below 40 mg/dL) occurred in 3.7% of patients (6.9% in the intensive-
control group and 0.5% in the conventional-control group). Both moderate and severe hypoglycemia
(HR 1.41; 95% CI, 1.21β1.62 and HR 2.10; 95% CI, 1.59β2.77, respectively) were independently
associated with death compared with the absence of hypoglycemia.
Thyroid crisis, also known as thyroid storm or critical thyrotoxicosis, is an uncommon manifestation of
hyperthyroidism known to occur in less than 10% of patients admitted for thyrotoxicosis. Thyrotoxicosis
has been associated with mortality rates of 8%β25%, if treated, and up to 100%, if untreated.
Myxedema coma is an uncommon severe manifestation of hypothyroidism, with mortality rates of
about 20%β25% with appropriate treatment and up to 80% without treatment.