Endocrine emergencies on the ward

• Thyroid

• Adrenal

• Pituitary

• Calcium

• Sodium

• Neuroendocrine

May 2016

Hyperthyroid

“Thyroid storm”

Pre-existing hyperthyroidism of any aetiology: graves,

multinodular goitre, amiodarone therapy

Precipitated by

Stress, withdrawal of treatment, radioiodine treatment,

surgery, intercurrent infection, ketoacidosis, tyrosine

kinase inhibitors

Clinical diagnosis: blood tests only helpful to a point

May 2016

Hyperthyroid

Clinical assessment

History:

Fever, sweating

Dehydration

Tachycardia/heart failure

Delirium/psychosis

Headaches

End stage: “apathetic”

May 2016

Thyroid storm

Treatment:

Fluids

Antithyroid drugs (blocks synthesis)

Iodide (blocks release)

Beta-blockers (adrenergic effects)

Steroids (?inhibit T4 to T3 conversion)

Cholestyramine

?plasmaphoresis

May 2016

TED

Thyroid eye disease Smokers more at risk/Radioiodine may destabilize

Most patients stabilize or improve

Inflammation the main warning marker

Don’t MRI every case

Colour vision and vision testing may help

Treatment:

stabilize TFTs

anti-inflammatory

radiotherapy/surgery last resort

specialist clinic

May 2016

ECG

Hypothyroidism/myxoedema coma

Precipitating factors

Infection

Other systemic disorder (vascular/respiratory)

Hypothermia

Hypoglycaemia

Drugs eg lithium

Mortality c20% reflecting underlying pathology

May 2016

Hypothyroidism/myxoedema coma

Precipitating factors

Infection

Other systemic disorder (vascular/respiratory)

Hypothermia

Hypoglycaemia

Drugs

May 2016

Hypothyroidism/myxoedema coma

Altered mental status

Reduced thermogenesis – hypothermia –hypoxia

Reduced cardiac output – hypotension – shock

Water retention- hyponatraemia

Differential diagnosis

1) Hypopituitarism: Low T4, Low TSH

2) Sick euthyroid: Low T3 (high rT3), Low/normal T4,

normal TSH

3) Starvation: low T3, low T4, low TSH

May 2016

Myxoedema treatment

Supportive treatment

Fluids

Inotrope support

Steroids

Large loading doses (IV) thyroxine

T4 500ug follwoed by 100ug daily

or T3 50 ug iv followed by 10 10ug qds

Look for atypical history such as weight loss/anorexia

May 2016

Amiodarone and thyroiditis

Amiodarone can cause hyper- or hypothyroidism

Type 1: patients predisposed to thyroid disease

goitre

“hot” gland on isotope scan

treat as for autoimmune hyperthyroidism/thyroid storm

Thyroidectomy last resort

May 2016

Amiodarone and thyroiditis

Type 2: Genuine thyroiditis

Release of stored thyroxine

Antithyroid drugs won’t help

“cold” isotope scan

(interleukin 6 may be elevated)

Supportive and antinflammatory treatment

Antithyroid treatment no use

Thyroidectomy last resort

Try and arrange radioisotope scan before starting treatment

LITHIUM: can also cause hyperthyroidism

May 2016

Addison’s History: c100% anorexia and weight loss

Other clinical clues

Unexplained general ill health

(student life style)

Pyrexia

Nausea

Abdominal pain

Hypoglycaemia

Hyponatraemia/Hyperkalaemia/Hypercalcaemia

Hypotension

May 2016

Addison’s Aetiology

Autoimmune

TB

Malignancy metastasis

Iatrogenic:

enzyme inducers (eg retrovirals)

steroid inhibitors

Sepsis/DIC/Anticoagulant therapy

Compliance/withdrawal of treatment

May 2016

Addison’s Pathophysiology

Glucocorticoids:

dilutional hyponatraemia

hypercalcaemia (loss of one-alpha hydroxylase inhibition)

hypoglycaemia

Mineralcorticoids

Na and water loss

K retention

Dehydration

May 2016

Addison’s Treatment:

Fluids: saline, dextrose

Send off cortisol and give steroids: don’t wait for a

synacthen test

Steroids should precipitate a diuresis

Identify aetiology

Remember sick day rules

May 2016

Severe headache

76 year old female with a longstanding history of non-

functioning pituitary macroadenoma managed

conservatively

Admitted with 2-3 day severe headache, obtunded,

hypotensive and hyponatraemic, vomiting, diplopia/visula

symptoms

Diagnosis? Investigations? Treatment?

May 2016

.

Investigations:

Na 130, K 4.2

MRI scan

Severe headache Aetiology: infarction of preexisting adenoma; haemorrhage

Cause: impaired blood supply via pituitary stalk? Not clear –

may reflect local anatomy and impaction of stalk on

diaphragmatic notch (cf Sheehans)

Management:

Steroids, fluids, assess visual fields

Urgent scanning

Neurosurgical opinion: may need surgery (may not)

May 2016

Hypercalcaemia

71 year old woman

Admitted with confusion, nausea, dehydration

Ca 3.5 mmol/L, PO4 0.72, PTH low normal

Responded to fluids over 4 day period

No need for bisphosphonates

No evidence of underlying malignancy (bloods, scanning)

Gradual improvement

When seen 4 weeks later calcium remains normal

Possible cause?

May 2016

Hyponatraemia assessment How low? –definition <136 mmol/L

Fluid retention/dilutional hyponatraemia (hypotonic): risk of

cerebral oedema

Loss of water from cells to the extracellular fluid (non-

hypotonic) – shift of water from intracellular to

extracellular, risk of cellular dehydration

May 2016

Hyponatraemia assessment Hypotonic hyponatraemia:

An excess of water in relation to existing sodium stores

Either due to inability to excrete water

Or excessive water intake

May 2016

Causes of hypotonic hyponatraemia

Decreased volume extracellular fluid:

diuretics

osmotic diuretics (eg hyperglycaemia)

adrenal insufficiency

nephropathy (salt wasting)

sodium loss (eg sweating)

sequestration (eg pancreatitis)

May 2016

Causes of hypotonic hyponatraemia

Normal volume extracellular fluid

Hypothyroid

Adrenal insufficiency

SIADH

iatrogenic (eg desmopressin, antiepileptics)

Infection (eg pulmonary)

Diet (eg potomania)

May 2016

Causes of hypotonic hyponatraemia

Increased extracellular fluid

CCF

Nephrotic syndrome

Cirrhosis

Renal failure

Pregnancy

May 2016

Causes of hypotonic hyponatraemia

Excessive water intake

Primary polydipsia

Accidental water ingestion

Sodium free irrigants

Tap water enema

May 2016

Consequences of hyponatraemia

Central nervous system dysfunction

Exaggerated by large (eg <125 mmol/L) or rapid decrease

Water gain by brain leads to cerebral oedema

Rapid adaptation: loss of solutes to reduce cerebral oedema

Slow adaptation: loss of organic osmolytes

Rapid correction by any method including fluid deprivation

can lead to shrinkage of the brain leading to osmotic

demyelination (pontine myelinolysis but not just pons)

May 2016

Assessment of the patient How low? <120 mmol/L a warning

How symptomatic (may reflects rapidity of onset)?

Any obvious possible cause : drugs, disease (eg cancer),

lifestyle, surgery, parturition etc., iatrogenic (eg iv

dextrose)

Specifically exclude Hypothyroidism and Adrenal

insufficiency (?hyperkalaemia)

Fluid replete or deplete? Clinical assessment

?SIADH: urine sodium/osmolalaity

May 2016

Options for correction: relatively

asymptomatic

Euvolaemia: check plasma and urine osmolality

Plasma <275, urine >100

Check urine sodium: >20 mmol/L, likely SIADH

Commence fluid restriction eg 1 litre initially

Look for underlying cause

May 2016

Options for correction: relatively

asymptomatic

Hypovolaemic: replace fluids – isotonic saline

Hypervolaemic: treat underlying cause (eg cardiac failure,

cirrhosis)

May 2016

Severe symptomatic hyponatraemia .

*Hypertonic 3% saline can also be administered at 0.5–1 mL/kg/hour with frequent monitoring every 2–4 hours

CNS = central nervous system; GCS = Glasgow Coma Scale; IV = intravenous;

Acute symptomatic hyponatraemia • CNS disturbance • Confusion • Headache • Drowsiness • Coma / altered GCS • Seizures • Encephalopathic

Move to a Level 2 monitored environment

Administration of hypertonic 3% saline* 150 mL IV over 20 min

Repeat after 20 min if no clinical improvement

Recheck serum [Na+] at 6, 12, 24 and 48 h for overcorrection (no more than 10 mmol/L

in 24 h, 18 mmol/L in 48 h)

A 78 year old patient with

liver metastases

• An incidental finding during diaphragmatic hernia repair

• She is on large doses of bisphosphonates for breast cancer mets

• Liver biopsy histology shows features of neuroendocrine tumour

• CT scanning shows a large pancreatic tumour with local lymph nodes

• Post-operatively she develops diarrhoea, hypovolaemia, hypokalaemia

• ?diagnosis

A 78 year old woman with liver mets

(cont)

• Gut hormone screen shows an elevated level of

VIP

• How would you treat?

• How do we know this is not a gastrinoma? (can

also present with diarrhoea)

19year old student

• Has a minor gynaeocological operation

• Hypertensive crisis post-anaesthetic

• Heart failure: resuscitation and transfer to ICU

• Investigations reveal grossly elevated plasma metanephrines

• CT scan shows large pararenal mass 6 cm

• Likely diagnosis paraganglioma

• Responds to alpha blockade but hypotensive, hyperkalaemic, random cortisol <50 nmol/L

• ?explanation

The end