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Endocrine emergencies  triner 2013
 

Endocrine emergencies triner 2013

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  • TSH and T4 levels do not differentiate hyperthyroidism from any of the other two states
  • In thyroid storm, as much as 50% of T3 comes from peripheral conversion of T4 to T3

Endocrine emergencies  triner 2013 Endocrine emergencies triner 2013 Presentation Transcript

  • Endocrine EmergenciesWayne Triner, DO, MPH Emergency Medicine
  • A 24 year old female presents with three days of progressive alteration of mental status. Today she was found by her partner to be highly anxious and seemingly with paranoid delusions. There is a history or prior alcohol use. She has not been at work as an artist (potter) for the past 4 days. PMHx: RA, Asthma Exam: Agitated, diaphoretic, shifting in bed, Unintelligible speech. 402, 136, 40, 132/68 HEENT, Neck, Lungs: normal Heart: tachy, regular, 2/6 systolic ejection murmur Abd: silent, non-distended, non-tender Neuro: mental status as described, non-focal, fine tremor Ext: no edema, no marks, no hot joints Derm: pink, moist, no rash A 42 year old female presents with three days of progressive alteration of mental status characterized as somnolence and intermittent anxiety. There is a history of prior alcohol use. She has not been at work as an artist (potter) for the past 4 days. PMHx: RA, Asthma Exam: Agitated, shifting in bed, Unintelligible speech. 342, 52, 40, 106/70 HEENT, Neck, Lungs: normal Heart: tachy, regular, 2/6 systolic ejection murmur Abd: silent, non-distended, non-tender Neuro: mental status as described, non-focal Ext: “brawny” edema on legs, no marks, no hot joints Derm: pink, moist, no rash A 46 year old female presents with three days of progressive alteration of mental status characterized as somnolence and intermittent anxiety. There is a history of prior alcohol use. She has not been at work as an artist (potter) for the past 4 days. PMHx: RA, Asthma Exam: Agitated, shifting in bed, Unintelligible speech. 342, 52, 40, 106/70 HEENT, Neck, Lungs: normal Heart: slow, regular, 2/6 systolic ejection murmur Abd: silent, non-distended, non-tender Neuro: mental status as described, non-focal Ext: no edema, no marks, no hot joints Derm: pink, moist, no rash A 24 year old male presents with three hours of progressive alteration of mental status characterized as highly aggitated. There is a history of prior alcohol and illicit substance use. He was encountered by police and “Tazer’d”. He is restrained, face-down on the ambulance gurney. PMHx: RA, Asthma Exam: Agitated, diaphoretic, shifting in bed, Unintelligible speech. 402, 184, 40, 236/130 HEENT, Neck, Lungs: normal Heart: tachy, regular, 2/6 systolic ejection murmur Abd: silent, non-distended, non-tender Neuro: mental status as described, onset of seizure upon arrival Ext: no edema, no marks, no hot joints Derm: pink, moist, no rash
  • Anxious, Delirious, Altered Hyperadrenergic / Hypermetabolic State Elevated blood pressure Tachycardia Delerium Hyperpyrexia Causes • Intoxication • Psychosis • Endocrine Excited Delirium
  • Hyperthyroidism Suppressed TSH Normal T4 Suppressed TSH Elevated T4 Subtle Symptoms Suppressed TSH Elevated T4 Dominant Symptoms Suppressed TSH Elevated T4 Severe Symptoms Altered Mental Status
  • Thyroid Storm (crisis) • Dx: Hyperthyroid with altered mental status • Generally with hyperpyrexia • Most common in 20’s and 30’s • 4:1 female to male • Incidence unknown • However, thyrotoxicosis may effect 2% of women • Small percentage of whom experience Thyroid Storm • Many Causes • Precipitated by; Sepsis Thyroid trauma Exogenous TH Iodine exposure “Hot nodule” Protein displacement (ASA, furosamide, NSAIDs) Surgery
  • Important Findings Thyrotoxicosis Symptoms Signs NeuroPsych Anxiety Nervousness / Agitation Coma Tremor Periodic paralysis Muscle wasting Hyperreflexia Endocrine Oligomennorhea Decreased libido Gynecomastia GI Hypermotility CardioVasc Palpitations Chest pain Dyspnea S. Tach (40%) A Fib (20%) High output failure Derm Hair loss Moist skin Pre-tibial myxedema
  • Laboratory and Imaging • Increased T4 / Decreased TSH • Increased Free T3 / T4 ratio • Likely of thyroid origin • Hyperglycemia • Adrenocortical dysfunction • Increased production • Increased metabolism • Reduced adrenal response to ACTH Stim test • Thyroid ultrasound • Increased vascularity • Nodules • Normal
  • Thyroglobulin Synthesis Iodination & Conjugation Proteolysis to T3 & T4 Secretion Peripheral Conversion of T4 to T3 Cellular Effect
  • Thyrotoxicosis/Storm Treatment • Supportive care • Controlling adrenergic effects • Stop synthesis of new T4 & T3 • Stop release of stored T4 & T3 • Preventing peripheral conversion of T4 to T3 • Ventilatory support • Thermoregulation • Hemodynamic support • Identify and treat underlying cause • Propranolol (β1 & β2) ONLY 1 Hr. FOLLOWING PTU • Iodine • SSKI • Lugol’s soln • PTU • Hydrocoritsone PTU • Short duration of action • Hepatotoxic • Prevents conversion of T4 to T3 Methimizole • Does not impact T4 to T3 conversion
  • Thyrotoxicosis/Storm Treatment 1. β-Blocker • Propanolol • Esmolol 2. PTU or methimizole 3. Hydrocortisone 4. Iodine* • SSKI • Lugol’s Solution 5. Generally, definitive control of hyperthyroidism isn’t considered until thyrotoxicosis/storm is controlled for at least six weeks.
  • A 24 year old female presents with three days of progressive alteration of mental status. Today she was found by her partner to be highly anxious and seemingly with paranoid delusions. There is a history or prior alcohol use. She has not been at work as an artist (potter) for the past 4 days. PMHx: RA, Asthma Exam: Agitated, diaphoretic, shifting in bed, Unintelligible speech. 402, 136, 40, 132/68 HEENT, Neck, Lungs: normal Heart: tachy, regular, 2/6 systolic ejection murmur Abd: silent, non-distended, non-tender Neuro: mental status as described, non-focal, fine tremor Ext: no edema, no marks, no hot joints Derm: pink, moist, no rash A 42 year old female presents with three days of progressive alteration of mental status characterized as somnolence and intermittent anxiety. There is a history of prior alcohol use. She has not been at work as an artist (potter) for the past 4 days. PMHx: RA, Asthma Exam: Agitated, shifting in bed, Unintelligible speech. 342, 52, 40, 106/70 HEENT, Neck, Lungs: normal Heart: tachy, regular, 2/6 systolic ejection murmur Abd: silent, non-distended, non-tender Neuro: mental status as described, non-focal Ext: “brawny” edema on legs, no marks, no hot joints Derm: pink, moist, no rash A 46 year old female presents with three days of progressive alteration of mental status characterized as somnolence and intermittent anxiety. There is a history of prior alcohol use. She has not been at work as an artist (potter) for the past 4 days. PMHx: RA, Asthma Exam: Agitated, shifting in bed, Unintelligible speech. 342, 52, 40, 106/70 HEENT, Neck, Lungs: normal Heart: slow, regular, 2/6 systolic ejection murmur Abd: silent, non-distended, non-tender Neuro: mental status as described, non-focal Ext: no edema, no marks, no hot joints Derm: pink, moist, no rash A 24 year old male presents with three hours of progressive alteration of mental status characterized as highly aggitated. There is a history of prior alcohol and illicit substance use. He was encountered by police and “Tazer’d”. He is restrained, face-down on the ambulance gurney. PMHx: RA, Asthma Exam: Agitated, diaphoretic, shifting in bed, Unintelligible speech. 402, 184, 40, 236/130 HEENT, Neck, Lungs: normal Heart: tachy, regular, 2/6 systolic ejection murmur Abd: silent, non-distended, non-tender Neuro: mental status as described, onset of seizure upon arrival Ext: no edema, no marks, no hot joints Derm: pink, moist, no rash
  • Excited Delirium Fatal Cases • 95% male • Mean age 36 • Almost all engage law enforcement • Resisted struggle • TASER use • Restraint Commonalities • Face-down restrain • Period of “giving-up” • Inability to resuscitate • Basil ganglion lack of dopamine (exhaustion hypothesis)
  • ExDS Management • Restrain supine • Benzodiazepines • Constant, direct observational monitoring • Control hyperthermia • Anticipate acidosis
  • A 24 year old female presents with three days of progressive alteration of mental status. Today she was found by her partner to be highly anxious and seemingly with paranoid delusions. There is a history or prior alcohol use. She has not been at work as an artist (potter) for the past 4 days. PMHx: RA, Asthma Exam: Agitated, diaphoretic, shifting in bed, Unintelligible speech. 402, 136, 40, 132/68 HEENT, Neck, Lungs: normal Heart: tachy, regular, 2/6 systolic ejection murmur Abd: silent, non-distended, non-tender Neuro: mental status as described, non-focal, fine tremor Ext: no edema, no marks, no hot joints Derm: pink, moist, no rash A 64 year old female presents with three days of progressive alteration of mental status characterized as somnolence and intermittent anxiety. There is a history of prior alcohol use. She has not been at work as an artist (potter) for the past 4 days. PMHx: RA, Asthma Exam: Agitated, shifting in bed, Unintelligible speech. 342, 42, 10, 106/70, SpO2 .86 HEENT, Neck, Lungs: normal Lungs: bi-basilar crackles Heart: slow, regular, 2/6 systolic ejection murmur Abd: silent, distended, non-tender Neuro: mental status as described, non-focal Ext: “brawny” edema on legs, no marks, no hot joints, dry skin A 46 year old female presents with three days of progressive alteration of mental status characterized as somnolence and intermittent anxiety. There is a history of prior alcohol use. She has not been at work as an artist (potter) for the past 4 days. PMHx: RA, Asthma Exam: Agitated, shifting in bed, Unintelligible speech. 342, 52, 40, 106/70 HEENT, Neck, Lungs: normal Heart: slow, regular, 2/6 systolic ejection murmur Abd: silent, non-distended, non-tender Neuro: mental status as described, non-focal Ext: no edema, no marks, no hot joints Derm: pink, moist, no rash A 24 year old male presents with three hours of progressive alteration of mental status characterized as highly aggitated. There is a history of prior alcohol and illicit substance use. He was encountered by police and “Tazer’d”. He is restrained, face-down on the ambulance gurney. PMHx: RA, Asthma Exam: Agitated, diaphoretic, shifting in bed, Unintelligible speech. 402, 184, 40, 236/130 HEENT, Neck, Lungs: normal Heart: tachy, regular, 2/6 systolic ejection murmur Abd: silent, non-distended, non-tender Neuro: mental status as described, onset of seizure upon arrival Ext: no edema, no marks, no hot joints Derm: pink, moist, no rash
  • Na 122 K 4.3 NaHCO3 36 Hgb 105 Labs and Findings
  • Hypothyroidism • General reflection of organ system slowing • Accumulation of glycosaminoglycans • Derm changes • Many underlying causes • Autoimmune Graves Hashimoto’s • Iatrogenic • Primary / Secondary None of this matters to us
  • Hypothyroidism Elevated* TSH Normal T4 Elevated* TSH Reduced T4 +Symptoms Elevated* TSH Reduced T4 Severe Symptoms 40% Mortality
  • Myxedema Coma Case Definition Severe hypothyroidism • Alteration of mental status • Hypothermia • Bradycardia Diagnostic Clues • Thyroid ablation or thyroidectomy • Often insidious Slow progressive reduced mental status • Hypothermia • Hypoventilation • Hyponatremia • Hypo…
  • Myxedema Coma Treatment • Consider the Diagnosis TSH & T4 • Supportive • Thermoregulation • Ventilation • Empirically treat adrenal insufficiency Spot cortisol level • Seek and treat SEPSIS • Avoid over resuscitation • Specific Thyroid Replacement T4 “physiologic” conversion to T3 T3 rapid onset of action T4 & T3
  • A 24 year old female presents with three days of progressive alteration of mental status. Today she was found by her partner to be highly anxious and seemingly with paranoid delusions. There is a history or prior alcohol use. She has not been at work as an artist (potter) for the past 4 days. PMHx: RA, Asthma Exam: Agitated, diaphoretic, shifting in bed, Unintelligible speech. 402, 136, 40, 132/68 HEENT, Neck, Lungs: normal Heart: tachy, regular, 2/6 systolic ejection murmur Abd: silent, non-distended, non-tender Neuro: mental status as described, non-focal, fine tremor Ext: no edema, no marks, no hot joints Derm: pink, moist, no rash A 64 year old female presents with three days of progressive alteration of mental status characterized as somnolence and intermittent anxiety. There is a history of prior alcohol use. She has not been at work as an artist (potter) for the past 4 days. PMHx: RA, Asthma Exam: Agitated, shifting in bed, Unintelligible speech. 342, 42, 10, 106/70, SpO2 .86 HEENT, Neck, Lungs: normal Lungs: bi-basilar crackles Heart: slow, regular, 2/6 systolic ejection murmur Abd: silent, distended, non-tender Neuro: mental status as described, non-focal Ext: “brawny” edema on legs, no marks, no hot joints, dry skin A 46 year old female presents with three days of progressive alteration of mental status characterized as somnolence and intermittent anxiety. She has been vomiting and expressing abdominal pain for 24 hours. There is a history of prior alcohol use. She has not been at work as an artist (potter) for the past 4 days. PMHx: Asthma Meds unknown Exam: Agitated, shifting in bed, Unintelligible speech. 382, 136, 40, 86/70 HEENT, Neck, Lungs: normal Heart: slow, regular, 2/6 systolic ejection murmur Abd: silent, non-distended, diffusely tender Neuro: mental status as described, non-focal Ext: no edema, no marks, no hot joints Derm: pink, moist, no rash A 24 year old male presents with three hours of progressive alteration of mental status characterized as highly aggitated. There is a history of prior alcohol and illicit substance use. He was encountered by police and “Tazer’d”. He is restrained, face-down on the ambulance gurney. PMHx: RA, Asthma Exam: Agitated, diaphoretic, shifting in bed, Unintelligible speech. 402, 184, 40, 236/130 HEENT, Neck, Lungs: normal Heart: tachy, regular, 2/6 systolic ejection murmur Abd: silent, non-distended, non-tender Neuro: mental status as described, onset of seizure upon arrival Ext: no edema, no marks, no hot joints Derm: pink, moist, no rash Her partner arrives and reports that she is a fragile asthmatic and has been to several EDs over the course of the past year. She has been on Prednesone almost continuously for 10 months.
  • Adrenal Crisis • Widely variable presentation • Largely dependent upon etiologies • Primary, secondary, tertiary • Wide range of etiologies • Precipitating event
  • Diagnostic Clues Findings • Physical Exam • Laboratory • Hyponatremia 85% • Neuro-psych The Traps • Surgical referral for abd pain and fever • Failure to recognize • Failure to carry out diagnostic tests
  • Approach to Management • Fluid resuscitation • Treat empirically with dexamethasone • Seek provoking cause • Short ACTH stim test 1. Baseline serum cortisol 2. Co-syntropin® 250 mcg IV 3. 30 and 60 minute serum cortisol • Normal outocome • 18-20 mcg/dl (500 nmol/L)
  • Endocrine EmergenciesWayne Triner, DO, MPH Emergency Medicine