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Non – Diabetic Endocrine Emergencies. “What an emerg doc needs to know” Rob Hall PGY3 December 5 th , 2002. WHY?. Uncommon Potentially lethal Diagnostic dilemmas ED treatment may be life-saving. Non – Diabetic Endocrine Emergencies. Outline. Objectives. How uncommon?

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Non diabetic endocrine emergencies

Non – Diabetic Endocrine Emergencies

“What an emerg doc needs to know”

Rob Hall PGY3

December 5th, 2002


Non diabetic endocrine emergencies1

WHY?

Uncommon

Potentially lethal

Diagnostic dilemmas

ED treatment may be life-saving

Non – Diabetic Endocrine Emergencies



Objectives
Objectives

  • How uncommon?

  • What defines thyroid storm, myxedemic coma, adrenal crisis?

  • What are the main clinical features?

  • When should these dx be considered?

  • What investigations are pertinent?

  • What is the emergency management?

  • When and how do you give stress dosing for chronic adrenal insufficiency?


37 yo female

Chest Pain and SOB

Denies any PMHx

Recent weight loss

Sinus tach 130

Temp 40

Agitated

Tremulous

Case



NOT GOOD!

CASE





Etiology of thyroid storm
Etiology of Thyroid Storm

Undiagnosed

Undertreated

(Grave’s disease or Mulitnodular toxic goiter)

Acute Precipitant

Thyroid

Storm


Thyroid storm1

1% of all hyperthyroids

Mortality 30%

Precipitants

Vascular

Infectious

Trauma

Surgery

Drugs

Obstetrics

Any acute medical illness

Thyroid Storm


Key features of thyroid storm
KEY FEATURES of Thyroid Storm

  • FEVER

  • TACHYCARDIA

  • ALTERED LOC

  • Features of underlying Hyperthyroidism

    • Weight loss, heat intolerance, tremors, anxiety, diarrhea, palpitations, sweating, CP, SOB

    • Goiter, eye findings, pretibial myxedema


When should you consider thyroid storm and what is the ddx
When should you consider Thyroid Storm and what is the ddx?

  • Infectious: sepsis, meningitis, encephalitis

  • Vascular: ICH, SAH

  • Heat stroke

  • Toxicologic

    • Sympathomimetics, seritonin syndrome, neuroleptic malignant syndrome, Delirium Tremens, anticholinergic syndrome


Investigations

Thyroid Testing

TSH

Free T4

Don’t need to order total T3/4, TBG, T3RU, FT3

Look for precipitant

ECG

CXR

Urine

Labs

Blood cultures

Tox screen

? CT head

? CSF

INVESTIGATIONS


Thyroid storm goals of management
Thyroid Storm: Goals of Management

  • 1 - Decrease Hormone Synthesis

  • 2 - Decrease Hormone Release

  • 3 - Decrease Adrenergic Symptoms

  • 4 - Decrease Peripheral T4 -> T3

  • 5 - Supportive Care


Decrease hormonal synthesis
Decrease Hormonal Synthesis

  • Inhibition of thyroid peroxidase

  • Propylthiouracil (PTU) or Methimazole (Tapazole)

  • PTU is the drug of choice

    • PTU 1000 mg po/ng/pr then 250 q4hr

    • No iv form

    • Safe in pregnancy

    • S/E: rash, SJS, BM suppression, hepatotoxic

    • Contraindications: previous hepatic failure or agranulocytosis from PTU


Decrease hormone release
Decrease Hormone Release

  • Iodine or lithium decreases release from hormone stored in colloid cells

  • MUST not be given until 1hr after PTU

  • Potassium Iodide (SSKI) 5 drops po/ng q6hr

  • Lugol’s solution 8 drops q6hr


Decrease adrenergic effects
Decrease Adrenergic Effects

  • Most important maneuver to decrease morbidity/mortality

  • Decreases HR, arrythmias, temp, etc

  • Propranolol 1 – 2 mg iv q 10 min prn

  • Propranolol preferred over metoprolol

  • Contraindications to beta-blockers

    • Reserpine 2.5 – 5.0 mg im q4hr

    • Guanethidine 20 mg po q6hr

    • Diltiazem


Decrease t4 t3
Decrease T4 -> T3

  • Corticosteriods

  • PTU and propranolol also have some effect

  • Dexamethasone 2 – 4 mg iv

  • Relative or absolute adrenal insufficiency also common


Supportive care
Supportive Care

  • Fluid rehydration

  • Correct electrolyte abnormalities

  • Control temperature aggressively

    • Ice, cooling blanket, tylenol, fans

  • Search for precipitant

    • Think vascular, infectious, trauma, drugs, etc


Summary of management

PTU

PROPRANOLOL

POTASSIUM IODIDE

STERIODS

SUPPORTIVE CARE

P3S2

Summary of Management


Apathetic hyperthyroidism
Apathetic Hyperthyroidism

  • Elderly (can be any age)

  • Altered LOC, Afib, CHF

  • Minimal fever, tachycardia

  • No preceeding hx of hyperthyroidism except weight loss

  • More COMMON than thyroid storm

  • Check TSH in any elderly patient with altered LOC, psych presentation, Afib, CHF



What is myxedemic coma
What is Myxedemic Coma?

  • Myxedema = swelling of hands, face, feet, periorbital tissues

  • Myxedemic coma = decreased LOC associated with severe hypothyroidism

  • Myxedemic coma/Myxedema generally used to mean severe hypothyroidism


Myxedemic coma

Hypothyroidism

Myxedemic Coma

Myxedemic Coma


Etiology of myxedemic coma
Etiology of Myxedemic Coma

Undiagnosed

Undertreated

(Hashimoto’s thyroiditis, post surgery/ablation most common)

Acute Precipitant

Myxedemic

Coma


Myxedemic coma1
Myxedemic Coma

  • Precipitants of Myxedemic Coma

    • Infection

    • Trauma

    • Vascular: CVA, MI, PE

    • Noncompliance with Rx

    • Any acute medical illness

    • Cold



When should myxedema be considered and what is the ddx
When should Myxedema be considered and what is the ddx?

  • Altered LOC

    • Structural vs metabolic causes of decreased LOC

  • Hypoventilatory Resp Failure

    • Narcotics, Benzodiazepines, EtOH intoxication, OSA, obesity hypoventilation, brain stem CVA, neuromuscular disorders (MG, GBS)

  • Hypothermia

    • Environmental

    • Medical: pituitary or hypothalamic lesion, sepsis


Myxedemic coma2
Myxedemic Coma

  • Investigations

    • TSH and Free T4

    • Look for ppt

      • ECG

      • Labs

      • Septic work up (CXR/BC/urine/ +/- LP)

      • Random cortisol

      • CT head


Management of myxedemic coma
Management of Myxedemic Coma

  • Levothyroxine is the cornerstone of Mx

    • Levothyroxine 500 ug po/iv (preferred over T3)

    • Ischemia and arrythmias possible: monitor

    • When in doubt, treat en spec

  • Other

    • Intubate/ventilate prn

    • Fluids/pressors/thyroxine for hypotension

    • Thyroxine for hypothermia

    • Stress Steroids: hydrocortisone 100 mg iv



Adrenal insufficiency
Adrenal Insufficiency

  • Primary = Adrenal disease = Addison’s

    • Idiopathic, autoimmune, infectious, infiltrative, infarction, hemorrhage, cancer, CAH, postop

  • Secondary = Pituitary

  • Tertiary = Hypothalamus

  • Functional = Exogenous steroids


Etiology of adrenal crisis
Etiology of Adrenal Crisis

Underlying Adrenal Insufficiency

(Addision’s and Chronic Steriods)

Acute Precipitant

Adrenal

Crisis


Acute adrenal crisis

Underlying Adrenal insufficiency

Addison’s disease

Chronic steroids

No underlying Adrenal insufficiency

Adrenal infarct or hemorrhage

Pituitary infarct or hemorrhage

Precipitants of Adrenal crisis

Surgery

Anesthesia

Procedures

Infection

MI/CVA/PE

Alcohol/drugs

Hypothermia

Acute adrenal crisis?


Adrenal hemorrhage
Adrenal Hemorrhage

  • Overwhelming sepsis (Waterhouse-Friderichsen syndrome)

  • Trauma or surgery

  • Coagulopathy

  • Adrenal tumors or infiltrative disorders

  • Spontaneous

    • Eclampsia, post-parturm, antiphospholipid Ab syndromes


Key features of adrenal crisis

Nonspecific

Nausea, vomiting, abdominal pain

Shock

Distributive shock not responsive to fluids or pressors

Laboratory (variable)

Hyponatremia, hyperkalemia, metabolic acidosis

Known Adrenal insufficiency

Features of undiagnosed adrenal insufficiency

Weakness, fatigue, weight loss, anorexia, N/V, abdo pain, salt craving, hyperpigmentation

Key Features of Adrenal Crisis





Adrenal crisis
Adrenal Crisis

  • Consider on the differential diagnosis of SHOCK NYD


Investigations1

Adrenal Function

Electrolytes

Random cortisol

ACTH

Look for Precipitant

ECG

CXR

Labs

EtOH

Urine

Investigations


Management of adrenal crisis
Management of Adrenal Crisis

  • Corticosteroid replacement

    • Dexamethasone 4mg iv q6hr is the drug of choice (doesn’t affect ACTH stim test)

    • Hydrocortisone 100 mg iv is an option

    • Mineralocorticoid not required in acute phase

  • Other

    • Correct lytes, fluid resuscitation (2-3L)

    • Glucose for hypoglycemia



Corticosteriod stress dosing who when how much
Corticosteriod Stress Dosing:Who? When? How much?

  • Who needs stress steroids?

    • ?Addison’s

    • ?Chronic prednisone

    • ?Chronic Inhaled Steroids

  • When?

    • ? Laceration suturing

    • ? Colle’s fracture reduction

    • ? Cardioversion for Afib

    • ? Trauma or septic shock

  • How Much?


Effects of exogenous corticosteroids
Effects of Exogenous Corticosteroids

  • Hypothalamic – Pituitary – Adrenal axis suppression

    • Has occurred with ANY route of administration (including oral, dermal, inhaled, intranasal)

    • Adrenal suppresion may last for up to a year after a course of steroids

    • HPA axis recovers quickly after prednisone 50 po od X 5/7


Streck 1979 pituitary adrenal recovery following a five day prednisone treatment
Streck 1979: Pituitary – Adrenal Recovery Following a Five Day Prednisone Treatment


Who needs corticosteroid stress dosing
Who needs Corticosteroid Stress Dosing?

  • Coursin JAMA 2002: Corticosteroid Supplementation for Adrenal Insufficiency

    • All patients with known adrenal insufficiency

    • All patients on chronic steroids equivalent to or greater than PREDNISONE 5 mg/day


Corticosteroid stress dosing la rochelle am j med 1993
Corticosteroid Stress Dosing: La Rochelle Am J Med 1993

  • ACTH stimulation test to patients on chronic prednisone

  • Prednisone < 5 mg/day

    • No patient had suppressed HPA axis

    • Three had intermediate responses

  • Prednisone > or = 5 mg/day

    • 50% had suppressed HPA axis, 25% were intermediate, 25% had normal response


Corticosteroid stress dosing
Corticosteroid Stress Dosing

  • What duration of prednisone is important?

  • What about intermittent steroids?

  • What about inhaled steroids?


Corticosteroid stress dosing summary of literature review
Corticosteroid Stress Dosing: Summary of literature review

  • Short courses of steroids are safe

    • Many studies in literature documenting safety of prednisone X 5 – 10 days

  • Wilmsmeyer 1990

    • Documented safety of 14 day course of prednisone

  • Sorkess 1999

    • Documented HPA axis suppression in majority of patients receiving prednisone 10 mg/day X 4 weeks

  • Many studies documenting HPA axis suppression with steroid use for > one month


Corticosteroid stress dosing1
Corticosteroid Stress Dosing

  • Inhaled Corticosteroids: Allen 2002. Safety of Inhaled Corticosteroids.

    • Adrenal suppression has occurred in moderate doses of ICS (Flovent 200 – 800 ug/day)

    • Adrenal suppression is more common and should be considered with chronic high doses of ICS (Flovent > 800 ug/day)


Corticosteroid stress dosing2
Corticosteroid Stress Dosing

  • “There is NO consistent evidence to reliably predict what dose and duration of corticosteroid treatment will lead to H-P-A axis suppression”

  • Why?


Corticosteroid stress dosing the bottom line
Corticosteroid Stress Dosing: The bottom line

  • Consider potential for adrenal suppression:

    • Chronic Prednisone 5 mg/day or equivalent

    • Prednisone 20 mg/day for one month within the last year

    • > 3 courses of Prednisone 50 mg/day for 5 days within the last year

    • Chronic high dose inhaled corticosteroids


When are stress steroids required
When are stress steroids required?

  • When is stress dosing required? (Cousin JAMA 2002)

    • Any local procedure with duration < 1hr that doesn’t involve general anesthesia or sedatives does NOT require stress dosing

    • All illnesses and more significant procedures require stress dosing



Corticosteroid stress dosing4
Corticosteroid Stress Dosing

  • MINOR

    • Double chronic steroid dose for duration of illness (only needs iv if can’t tolerate po)

  • MODERATE

    • Hydrocortisone 50 mg po/iv q8hr

  • MAJOR

    • Hydrocortisone 100 mg iv q8hr


Corticosteroid stress dosing5
Corticosteroid Stress Dosing

  • What about procedural sedation?

    • ? Stress dose just before sedation/procedure

    • Recommended by Coursin JAMA 2002 but NO supporting literature specific to procedural sedation in emerg

    • Should be done --------> Hydrocortisone 50 mg iv just before procedure and then continue with normal steroid dose



Non diabetic hypoglycemia

Fasting

Insulinoma

Insulin

Sulfonylureas

Liver dz

H-P-A axis

Fed

Alimentary hyperinsulinism

Congenital deficiency

What labs to order BEFORE glucose administration????

Serum glucose

C-peptide level

Insulin level

Cortisol

Sulfonylurea level

Non –diabetic Hypoglycemia


Non diabetic endocrine emergencies2
Non-diabetic Endocrine Emergencies

  • Recognize key features

  • Pattern of underlying dz + precipitant

  • Emergent management

    • P3S2, levothyroxine, dex

    • Supportive care and look for precipitant

  • Consider corticosteroid stress dosing



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