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ENDOCRINE EMERGENCIES. NANDALAL BAGCHI. CASE 1. 40 YEAR OLD WOMAN ONE DAY AFTER GALL BLADDER SURGERY NAUSEA , VOMITING EXTREME WEAKNESS HYPOTENSION, POOR RESPONSE TO FLUIDS AND PRESSORS SERUM K-5.5, Na-120. CLINICAL CLUES: PRIMARY. HYPERPIGMENTATION HYPERKALEMIA VITILIGO.

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endocrine emergencies

ENDOCRINE EMERGENCIES

NANDALAL BAGCHI

case 1
CASE 1
  • 40 YEAR OLD WOMAN
  • ONE DAY AFTER GALL BLADDER SURGERY
  • NAUSEA , VOMITING
  • EXTREME WEAKNESS
  • HYPOTENSION, POOR RESPONSE TO FLUIDS AND PRESSORS
  • SERUM K-5.5, Na-120
clinical clues primary
CLINICAL CLUES: PRIMARY
  • HYPERPIGMENTATION
  • HYPERKALEMIA
  • VITILIGO
clinical clues secondary
CLINICAL CLUES: SECONDARY
  • PALE SKIN WITHOUT MARKED ANEMIA
  • DEFICIENCY OF OTHER PITUITARY HORMONES
  • PAST USE OF GLUCOCORTICOIDS
  • HEADACHE
  • VISUAL SYMPTOMS
causes primary chronic
CAUSES: PRIMARY,CHRONIC
  • AUTOIMMUNE
  • INFECTIONS: TBC,FUNGAL, HIV
  • METASTATIC CARCINOMA
  • ADRENOMYELONEUROPATHY
  • ISOLATED GC DEFICIENCY
causes secondary chronic
CAUSES: SECONDARY,CHRONIC
  • TUMORS
  • SURGERY, IRRADIATION
  • LYMPHOCYTIC HYPOPHYSITIS
  • GRANULOMAS
  • CHRONIC GC THERAPY
  • CRH DEFICIENCY
causes acute
CAUSES: ACUTE
  • ADRENAL HEMORRHAGE/NECROSIS [SEPSIS, BLEEDING]
  • POSTPARTUM NECROSIS OF THE PITUITARY
  • PITUITARY APOPLEXY
  • HEAD TRAUMA
laboratory diagnosis
LABORATORY DIAGNOSIS
  • BASELINE ACTH, CORTISOL
  • COSYNTROPIN TEST
  • MRI PITUITARY[ SELECTED CASES]
primary vs secondary
PRIMARY VS. SECONDARY
  • PROLONGED ACTH STIMULATION
  • RENIN, ALDOSTERONE
  • INSULIN HYPOGLYCEMIA
  • METYRAPONE
  • CRH STIMULATION TEST
treatment
TREATMENT
  • HYDROCORTISONE IV 100MG FOLLOWED BY 100-200MG OVER NEXT 24H
  • GLUCOSE SALINE 2-3L
  • MONITOR ELECTROLYTES
  • ORAL THERAPY IN 1-2 DAYS
    • HYDROCORTISONE
    • FLUDROCORTISONE
slide11
CASE
  • 30 YEAR OLD WOMAN
  • ADMITTED WITH PNEUMONIA
  • MILDLY DISORIENTED
  • TEMP. 103, PULSE 150/MIN
  • THYROID ENLARGED
  • TREMOR, BRISK DTR, WARM MOIST SKIN
thyroid storm diagnosis
THYROID STORM: DIAGNOSIS
  • EVIDENCE OF SEVERE HYPERTHYROIDISM
  • END ORGAN FAILURE: CNS,CVS
  • MAJOR STRESSFULL EVENT
  • TFT CONSISTENT WITH OVERT HYPERTHYROIDISM
  • A CLINICAL DIAGNOSIS
causes
CAUSES
  • GRAVES” DISEASE
  • RARELY
    • TOXIC NODULAR GOITER
    • EXCESSIVE THYROXINE INGESTION
    • OTHER CAUSES
treatment1
TREATMENT
  • BLOCK HORMONE SYNTHESIS
    • PTU 150MG EVERY 6H
  • BLOCK HORMONE RELEASE
    • SSKI 5-10 DROPS EVERY 8H
  • BLOCK BETA ADRENERGIC SYSTEM
  • PREDNISONE 30-40 MG OVER 24H
  • PLASMAPHERESIS, DIALYSIS
  • FLUIDS, COOLING, NO ASA
slide15
CASE
  • 70 YEAR OLD WOMAN, LIVES ALONE
  • POORLY RESPONSIVE
  • VITALS: T 92, P 50/M, R 10/M, BP 90/60
  • COOL DRY SKIN,PUFFY EYES
  • THYROID NOT PALPABLE, NO NECK SCAR
  • DTR: SLOW RETURN
  • STOOL: MELENA
myxedema coma diagnosis
MYXEDEMA COMA: DIAGNOSIS
  • EVIDENCE OF SEVERE HYPOTHYROIDISM
  • EVIDENCE OF END ORGAN FAILURE
    • CNS,CVS,RENAL,RESPIRATORY
  • PREDISPOSING CAUSES
  • R/O OTHER CAUSES OF HYPOTHERMIA
  • LABS CONSISTENT WITH SEVERE DISEASE
diagnostic problems
DIAGNOSTIC PROBLEMS
  • HYPOTHERMIA HAS MANY CAUSES
  • COMA HAS MANY CAUSES
  • INFECTION IS HARD TO RECOGNIZE
predisposing factors
PREDISPOSING FACTORS
  • INFECTION
  • DRUGS: ANESTHETICS, OTHER CNS DEPRESSANTS
  • HYPOTENSION e.g. GI BLEEDING.
  • CARDIAC CAUSES: MI,CHF
  • PROLONGED COLD EXPOSURE
treatment2
TREATMENT
  • SUPPORTIVE
    • CAREFUL WARMING
    • SUPPORT BP, RESPIRATION
    • TREAT UNDERLYING DISEASE
  • L-THYROXINE IV 250-500 mcg BOLUS, THEN 100 mcgDAILY AFTER 48H OR,
  • TRIIODOTHYRONINE 12.5 mcg EVERY 8H