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hyperthyroidism, depression or psychotic states such as bipolar disorder or schizophrenia.
Plan:
Treatment
Primary: Acute: Rapidly infuse normal saline solution (2 liters rapidly, then 250-500 cc hour, adjust rate of
infusion based on pulse, blood pressure, and overall state of well-being); administer dexamethasone 4 mg
intravenously as a single dose. Replacement therapy with hydrocortisone, 20 mg each morning and 10 mg
each evening should be administered after resolution of acute symptoms until a definitive medical evaluation
by a physician.
Alternative: Prednisone 5-7.5 mg once daily in the morning may be substituted as replacement therapy
in lieu of hydrocortisone.
Primitive: If no glucocorticoid medication is available, attempt hemodynamic stabilization by aggressive
intravenous hydration using normal saline solution at 250-500 cc per hour or more.
Empiric: In any case of shock or severe hypotension without obvious blood loss, render empiric treatment
to cover the possibility of adrenal insufficiency. Accompany wide-open intravenous infusion of isotonic saline
solution with the administration of dexamethasone 4 mg as an IV bolus every 24 hours (or, alternatively,
hydrocortisone 100 mg may be given IV, every 8 hours).
Patient Education
General: Taking medication daily is essential to preserving health. In the event of any illness, double the daily
dose of steroid medication for the duration.
Activity: No restrictions.
Diet: No restrictions. If steroid medication is unavailable, a high-salt diet can help minimize symptoms,
preserve blood pressure and functional status.
Medications: Chronic steroid use can result in weight gain and other side effects.
Prevention and Hygiene: In developing countries, test the patient and their close contacts for TB, the most
common cause of this syndrome in developing countries.
No Improvement/Deterioration: Seek medical care promptly for any acute illness resulting in vomiting or if
an illness persists for more than a day on double-dose steroid therapy.
Follow-up Actions
Return evaluation: Expect rapid improvement in symptoms after initiating steroid therapy. After starting
maintenance therapy, reassess symptoms and vital signs, including weight and blood pressure within one
week. If improved, re-evaluate every 1-3 months.
Evacuation/Consultation Criteria: Referral to a medical center for appropriate confirmatory testing, and
treatment.
Endocrine: Diabetes Mellitus
Col Stephen Brietzke, USAF, MCIntroduction: Diabetes mellitus (DM), the most common disease of the endocrine system, is characterized by
abnormally high blood glucose levels. Diabetes mellitus results from either absolute deficiency of insulin (type
1 diabetes), or from subnormal target cell response to insulin (insulin resistance) combined with failure to
compensate for this insulin resistance by producing higher concentrations of insulin (relative insulin deficiency)
(type 2 diabetes). Type 2 diabetes accounts for up to 80-90% of all cases of diabetes. In the Americas
and Western Europe, most cases of type 2 diabetes are associated with obesity, a sedentary lifestyle
and/or a genetic predisposition. Type 1 diabetes is most often caused by autoimmune destruction of the
insulin-producing beta cells within the pancreatic islets. Even though there are genetic factors which confer
susceptibility, it is unusual to identify multiple first-degree relatives with type 1 disease. Patients with
type 1 diabetes may exhibit other autoimmune diseases, such as hypothyroidism, rheumatoid arthritis or
hyperthyroidism due to Graves’ disease. DM due to another endocrine disease is called secondary diabetes
mellitus. Gestational DM encountered during pregnancy is reversible if not prior to or post-gestation. These