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Endocrine Emergencies
Corey M. Slovis, M.D.Vanderbilt University Medical Center
Metro Nashville Fire DepartmentNashville International Airport
Nashville, TN
Hyperthyroidism
TSHTell us what the Pituitary is Seeing
Almost undetectable = Hyperthyroid
No stimulation needed
Very High = Hypothyroid
Pituitary wild to get thyroid stimulated
Everything is Hyper in Hyperthyroidism except menses
Amenorrhea is due to undetectable TSH levels which blocks LH Surge
What are some common ED complaints that should make us think: R/O Hyperthyroidism?
Think Thyroid Disease “ED Crocks”
• Anxious and multiple nonspecific complaints
• Young, healthy but “weak”
• Amenorrhea but negative pregnancy test
• Diarrhea but otherwise healthy
• Palpations in exercising “over-achiever”
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The one arrhythmia to always make you think of Hyperthyroidism is
Atrial Fibrillation with Rapid Ventricular Response
The most common cause of Hyperthyroidism in the ED is:
Graves Disease
Activation of Graves Disease is usually due to:
• Discontinuing Medication
• Triggering Stress
When you see a Hyper orHypo Thyroid Crisis, think:
Precipitating Cause!
When you see a Hyper orHypo Thyroid Crisis, think:
Adrenal
HyperthyroidismR/O Triggering Stress
• Infection
• Pregnancy
• Trauma
• Recent surgical procedures
• High emotional stress
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J Emerg Med 1996;14:697-701 Am J Emerg Med 2001;19:603-604
Treatment of Hyperthyroidism
• ABC’s
• NGT
• Block peripheral action
• Block synthesis
• Avoid relative hypoadrenalism
Treatment of Hyperthyroidism ABC, NGT
• Perform Opening Gambit
• Patients volume contracted
• High metabolism = Low Glucose Reserves
• Tachyarrhythmias common
• Treat the disease….Not just the rhythm!
The Opening Gambit
• O2
• O2 Sat
• IV Access
• ECG Monitor
• 12 Lead ECG
I
I
Intake of Iodine
I T3
T4
I2
Synthesis of Thyroid Hormone (Organification)
Release of Active T4 , T3
T4 T3
Conversion of T4 to T3
Brain
Heart
Body
Stimulus effects on the body
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Treatment of Hyperthyroidism ABC, NGT
Begin D5NSS at 200 cc/hr
Beta Blockers in Hyperthyroidism
• As much as it takes but not too much
• Inderal 1mg Q5 minutes
• Esmolol 1/2 pts Wt in Kgs IV push
e.g.: 60 kg woman = 60/2 = 30 mg IV push = 3 mg/min
then 1/10 of loading dose/min
I
II
T3
T4
T4 T3
Brain
Heart
Body
I2
Beta Blockers
And also decrease peripheral conversion of T4 T3
Beta Blockers block peripheral actions of Thyroid Hormone
PTU in Hyperthyroidism
• Blocks T3 and T4 Formation
• Works Rapidly
• Must be given orally
• Also decreases T4 T3 conversion
• Dose is 250 mg TID
But load with 750 mg po acutely
I
II
T3
T4
T4 T3
Brain
Heart
Body
I2
PTU
PTU blocks the formation of Active Thyroid Hormone
And decreases T4 T3 conversion
Steroids in Hyperthyroidism
• Preserve Homeostasis
• Avoid Hypo Adrenal Crisis
• Decrease T4 T3 Conversion
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I
II
T3
T4
T4 T3I2
Steroids
Steroids help decrease T4 T3 conversion
Steroids help borderline hypoadrenalism
Brain
Heart
Body
Brain
Heart
Body
Steroids supports organ function
Steroids
• Use in Thyroid Disease
• Use in Adrenal Disease
• Hydrocortisone 100 mg
• Decadron 6 mg
• Solumedrol 80 – 120 mgs
Steroid Equivalent Doses 20, 5, 4, .75
• 20 mg of Hydrocortisone
• 5 mg of Prednisone
• 4 mg of Solumedrol
• 0.75 mg of Decadron
I
II
T3
T4
T4 T3
Brain
Heart
Body
I2
Support
Brain
Heart
Body
PTU SteroidsPTUBetaBlockers
Steroids
Beta Blockers
Organification Conversion Effects
Treatment of Hyperthyroidism
Treatment of Thyroid Storm
• ABC/NGT
• Titrate Inderal 1 mg Q 3-5 min
• Begin PTU 750 mg PO
• Bolus with Steroids
• Administer Iodine
I
II
T3
T4
T4 T3
Brain
Heart
Body
I2
Iodine (1)
Iodine administration stimulates T4 formation
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Treatment of Hyperthyroidism-Iodine
if PTU already onboard
Large doses of iodine blocks release ofactive Thyroid Hormone and
new Formation
I
II
T3
T4
T4 T3
Brain
Heart
Body
I2
Iodine (2)
If you give Iodine, block T3/T4 formation by first giving PTU
But: also stimulates new T3 and T4 formation
Iodine in Large Doses Blocks Release of Active T4 and T3
Where in the hospital
is Iodine?
Treatment of Thyroid Storm
• IV D5NSS 200 cc/hr
• Titrate Inderal 1 mg Q5
• PTU 750 mg PO
• Bolus Steroids (100mg Hydrocortisone)
• Iodine for Storm (1 gram Hypaque)
I
II
T3
T4
T4 T3
Brain
Heart
Body
I2
Brain
Heart
Body
PTU Iodine SteroidsPTUBetaBlockers
Steroids
Beta Blockers
Organification Release Conversion Effects Support
Treatment of Thyroid Storm
Hypothyroidism
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What patient types should make us consider
Hypothyroidism?
Hypothyroidism“Chronic complainers”
• Elderly with dementia
• CHF patient on diuretics with hyponatremia
• Digitalis toxicity – even with decreasing dosage
• Hypertensive with repeat episodes of hypotension
• Fecal impaction, abdominal cramps, constipation
• “Would minoxydil help?” – hair loss
Most acute and some chronic ED presentations of
hypothyroidism have a:
precipitating cause:
Find it!
Myxedema
• A hyperthyroid patient with:
AMS
Significant Vital Sign Abnormalities
+
When should you consider myxedema coma?
Classic Myxedema Coma Patients:
• AMI with shock, poor response to pressors
• New Sick Sinus Syndrome, poor response to atropine
• Hypothermia in the spring, summer or fall
• Hypothermia that won’t warm up
• AMS with sepsis
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Myxedema Coma5 Vital Signs
• BP: Hypotensive• P: Bradycardic• RR: Hypercarbia
• Temp: Hypotensive
• O2 sat: Hypoxic
Hypothyroid Patients Hypoventilate!
A hypothermic patient presents to the ED.
How many therapies should you always consider?
Hypothermia Therapies to Consider
• Heated O2
• N,G,T
• Synthroid
• Steroids
• Antibiotics
Begin Therapy for Hypothermia
Narcotic OD, Hypoglycemia,
Hypothyroid
Hypoadrenal/Hypothyroid
Sepsis
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Wernicke’s
100 ugm (0.1 mg) of synthroid (T4) daily.
Treatment of Hypothyroidism: Treatment of Myxedema Coma
Secure ABC’s: High FiO2: Consider intubation
Consider NGT: Beware hypoglycemia
Thyroid Replacement: 400 ugm of Synthroid or 100 ugm T3
Steroids: 100 mg IV of hydrocortisone, or decadron
R/O underlying disease: R/O AMI, sepsis, head trauma, UTI etc.
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Hypothyroidism = Hyponatremia Hypothyroid = Hypoadrenal
A hypothyroid asthmatic
• How many clues to this endocrine disease?
• What medication is key to curing him?
with AIDSpresents with purpuric lesionson his chest.
Meds include coumadin.
HypoAdrenalism
Adrenal Hormones
• Aldosterone: Salt and Water Retention
• Cortisol: Energy – Pressor Response
“Salt Water Energy Drink”
Consider Adrenal Insufficiency• Asthmatics (or history of steroid use)
• AIDS (infiltrative disease with MAI)
• Myxedema (or any endocrine disease)
• Meningiococcemia and Fulminant Sepsis
• Any “Refractory Shock Patient”- BP hypotensive- P bradycardic- Temp hypothermic
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Consider Adrenal Insufficiency
• In any Hyperkalemic patient without renal failure
• In any Hypotensive patient not responding to volume or pressors
• In any Hypothermic patient not rewarming
Treatment of Hypoadremalism
• Volume
• Glucose
• Sodium
• Steroids
• Diagnosis
Therapy of Adrenal Insufficiency
• Secure ABCs– O2, Volume, Na (D5NSS, 250-1000 cc/hr)
• NGT– Glucose (D5NSS, 250-1000 cc/hr)
• Draw Red Top– Label time drawn
IV Therapy in Hypoadrenalism
• Patients need sodium – Volume at 250 - 1000 cc/hr
– Bolus for shock
• Patients need glucose– Use D5NSS
– Not just NSS
Therapy of Adrenal Insufficiency
• Steroids – 6 mg Decadron
+– 250 ugm Corticotropin
• Find Cause– R/O infection, infarction– Redraw red top in 30-60 min
Diagnosing Addison’s DiseaseCosyntropin Stimulation Test
• Draw red top tube*
• Give 6 mg Decadron
• And 250 ugm Corticotropin
• Draw second red top 30 – 60 min later*
• See if Cortisol level 20 (or doubles)
* Label Times!!
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Steroid Equivalent Doses 20, 5, 4, .75
• 20 mg of Hydrocortisone
• 5 mg of Prednisone
• 4 mg of Solumedrol
• 0.75 mg of Decadron
Failure of cortisol level to rise to 20 ugm/dl, or at least double.
Diagnosis of Hypoadrenalism
A 54 year old female s/p gastrectomy presents with AMS and hypoglycemia. She is rehydrated and improves significantly.
• Why does she develop ataxia and ophthalmoplegia?
• Can thiamine be given in IV?
• Should it precede glucose?
• What is the classic triad vs the unusual pentad?
A medical student faints while
urinating. His BP is 300/200
and he is sweating, but 5
minutes later is 120/70.
Pheo = Epinephrine SurgesWhat three symptoms
should make you think of pheochromocytoma?
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The Classic Triad of Pheos
Episodic Headache
with
and
Palpitations
Sweating
Headache, Palpitations, Sweating
Think Pheo
Suspect Pheochromocytoma
• Chronic Hypertension
• Paroxsyml Hypertension
• Headache
• Palpitations
• Sweating
+/or
plus
Paroxysmal Hypertension
Think Pheo
Major Symptoms of Pheochromocytomas
• Hypertension
• Sweating
• Tachycardia
• Headache
• Apprehension
Pheochromocytoma Symptoms
• Almost always paroxysmal
• Often last only a few minutes
• Rarely more than 1 hour
• Reoccurs in days, weeks, or months
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Hypertension in Pheo’s 50:50
Hypertension is the number 1 symptom BUT…
50% have chronic Hypertension + Paroxysmal
50% have WNL Blood Pressure + Paroxysmal
• Nipride
and/or
• Consider Phentolamine
Hypertenvise Crisis in Pheo
1 Hypothyroid
2 Hyperthyroid
3 Hypoadrenalism
4 Wernicke’s
5 Pheochromocytoma
Name that Endocrinopathy A. A 48 year old male asthmatic suffers an inferior AMI and does not respond to pressors. Hypoadrenal
B. A 68 year old elderly female presents in coma due to hypoglycemia. She does not wake up after 2 amps of D50. Hypoadrenal…. Hypothyroid too?
C. A hypothermic alcoholic does not rewarm.Wernicke’s…. Hypoadrenal too?
D. A 28 year old woman presents in PSVT which keeps relapsing after therapy with adenosine, verapamil and 200 ws DC cardioversion.
Hyperthyroid
E. Hypertensive bleed. Pheo
F. Hyponatremic seizure. Hypothyroid
G. Sodium of 128. Hypothyroid, Hypoadrenal
H. Sick sinus syndrome. Hypothyroid
I. Weight loss. Hyperthyroid
J. Anorexia in healthy person. Hyperthyroid
K. Meningitis and WNL CSF. Thyroid Storm
L. AIDS. Hypoadrenal.. Wernicke’s Too?
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M. Unresponsive Wernicke’s (coma, hypothermia, hypotension, bradycardia)
Hypoadrenal
N. pCO2 of 45. Hypothyroid
O. Acute psychotic runner. Hyperthyroid Pseudo Pheo???
P. Hyponatremia, hyperkalemia. Hypoadrenal
Q. Fecal impaction in NH patient. Hypothyroid
R. Coma with pinpoint pupils, bradycardia and hypotension. Wernicke’s
S. Persistent hypotension s/p major trauma no bleeding site found. Hypoadrenal
Summary
Be Gentle in NKHC
Refractory = Endocrine
Think Precipitating Causes
“Sepsis” = R/o Endocrine
Give Thiamine More