W. Heath Giles, M.D.University of Tennessee College of Medicine ChattanoogaAssistant Professor of SurgeryAssociate Residency Program Director
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Understand the presentation, work-up, and treatment of endocrine emergencies encountered in the ICU
Adrenal Insufficiency
Thyroid Storm
Hypercalcemia
Father of Endocrine Surgery
Nobel Prize 1909 (Thyroid)
Director of Surgery Clinic at Berne
Instructed military doctors
Produced most extensive research on gunshot wounds and the basis of the modern ideas of the mode of action of small caliber missiles with high initial velocity.
Primary (Addison’s disease) Adrenocortical disease
Both cortisol and mineralocorticoid deficiency Secondary Pituitary (ACTH)
Abrupt withdrawal glucocorticoids
Cortisol deficiency only Tertiary Hypothalamus (CRH)
Cortisol deficiency only
Symptoms
Weakness/fatigue
Anorexia
Nausea/vomiting
Myalgia/arthralgia
Headaches
Depression
Postural dizziness
Physical Exam
Hypotension
Tachycardia
Fever
Increased pigmentation
Laboratory findings
Hyponatremia
Hyperkalemia
Hypoglycemia
Hypercalcemia
Eosinophilia
Clues
Hemodynamic instability despite adequate fluid resuscitation
▪ Hyperdynamic circulation
▪ Decreased SVR
Ongoing evidence of inflammation without obvious source not responsive to empiric tx
Treatment Large bore IV access Serum electrolytes, glucose, cortisol, ACTH Bolus 2-3 liters NS or D5NS If no previous diagnosis adrenal insufficiency
▪ Dexamethasone 4mg IV
If known diagnosis ▪ Hydrocortisone 100mg IV
Correction electrolytes Supportive measures
Rare but life-threatening Graves’ Disease, TMNG, Solitary toxic adenoma Can occur in patients with long-standing
untreated hyperthyroidism but often precipitated by acute event Surgery
Trauma
Infection
Acute iodine load
Parturition
Pathophysiology unclear
Rapid rate of increase in serum thyroid hormone
Increased responsiveness to catecholamines
Enhanced cellular responses to thyroid hormone
Mortalilty: 20%
Presentation Tachycardia
Fever (104 – 1060)
CNS dysfunction▪ Agitation, delirium, coma
GI symptoms▪ N/V, abd pain
Tremor
Goiter
Exophthalmos
Warm and moist skin
Elderly Toxic goiter
New onset CHF/afib
Diagnosis
Thyrotoxicosis
▪ Elevated free T4/T3
▪ Suppressed TSH
Nonspecific
▪ Hyperglycemia
▪ Hypercalcemia
▪ Abnormal LFT
Burch HB, Wartofsky L. Life-threatening thyrotoxicosis. Thyroid storm. Endocrinol Metab Clin North Am 1993; 22:263
Treatment Supportive care
▪ IVF or diuretics for CHF
▪ Cooling blankets and Acetaminophen (NOT ASA)
▪ Treat precipitating condition
Beta blocker ▪ control increased adrenergic tone
▪ Propranolol 60-80 mg PO Q4-6hrs
▪ Esmolol
▪ *Calcium Channel blocker if unable to take BB x
Treatment
Thionamide▪ block new hormone synthesis
▪ PTU 200mg PO Q4hrs (also blocks peripheral T4T3)
▪ Methimazole 20mg PO Q4-6hrs
Iodine solution ▪ block release of hormone
▪ Lugol’s solution 10 drops Q8hrs
▪ SSKI 5 drops Q6hrs
▪ *wait at least 1 hr after thionamidex
x
xx
Glucocorticoids
▪ reduce T4T3 conversion
▪ Hydrocortisone 100mg IV Q6hrs
Surgery▪ If unable to take thionamide and
need urgent correction of hyperthyroidism
x
Causes Hyperparathyroidism
Malignancy
Thyrotoxicosis
Milk alkali syndrome
Hypervitaminosis D
Lithium
Thiazide diuretics
Adrenal insufficiency
Theophylline toxicity
Presentation GI
▪ Constipation▪ Pancreatitis▪ PUD
Neuropsychiatric▪ Anxiety▪ Depression▪ Lethargy▪ Confusion▪ Coma
Renal dysfunction▪ Kidney stones▪ ARF▪ Nephrogenic DI
CV▪ Shortened QT▪ Arrhythmia▪ HTN▪ Cardiomyopathy
Musculoskeletal▪ Weakness▪ Bone pain▪ Fracture (osteoporosis)
Mild (Calcium < 12 mg/dl)
No immediate treatment necessary
Avoid aggravating factors
▪ Thiazides
▪ Volume depletion
▪ Inactivity
▪ High Ca diet
Moderate (Calcium 12-14 mg/dl)
If chronic and mildly symptomatic avoid aggravators
If acute rise with change in sensorium treat as severe
Severe (Calcium > 14 mg/dl)
Volume expansion with isotonic saline 200-300 ml/hr
Loop diuretic only for renal failure and CHF
Calcitonin 4 IU/kg
Zoledronic acid 4mg IV over 15 min
Cooper and Stewart. Corticosteroid Insufficiency in Acutely Ill Patients. NEJM, Feb 2003.
UpToDate Morita, Dackiw, and Zeiger. Endocrine Surgery. 2010 Cameron. Current Surgical Therapy. 8th Ed. Townsend et al. Sabiston Textbook of Surgery. 17th Ed.