2018 UF ED/Trauma Symposium

1. Metabolic
Emergencies
SPENCER TOPP, MD
DEPARTMENT OF EMERGENCY MEDICINE
UF COLLEGE OF MEDICINE-JACKSONVILLE

2. Objectives
 Review common case presentations of several life-threatening
metabolic emergencies
 Discuss appropriate diagnostic criteria and approach to metabolic
laboratory analysis
 Review treatment options, particularly those required in the emergent
setting

3. Case #1
 28 y/o AAF, unknown PMH, presents to the ED for altered
mental status. Co-workers noticed her “acting funny” at work
today.
 Vitals upon arrival: HR 145, BP 110/65, RR 22, Temp 99.4, O2
sat 99%.
 Upon exam, you see a disheveled female, mild agitation,
unable to focus and cooperate with much of the exam. States
upon questioning, “My belly hurts”, but otherwise unable to
provide any further information
 What else would you like to know?
 Any particular orders?

4. Case #1
 CBC- WBC 16 (6% Bands), H/H 15.2/45.8, platelets 420
 BMP Na 136, K 5.2, Cl 104, Bicarb 24, BUN 20, Cr 1.4, Glucose 120
 Lactate 3
 LFT’s WNL, Lipase normal
 U/A- 3 WBC, no RBC, nitrate neg, Spec Grav 1.030
 TSH <.001, T3/T4 Pending

5. Thyroid Storm
 Rare, life-threatening condition characterized by severe clinical
manifestations of thyrotoxicosis
 Often precipitated by acute event (surgery, trauma, infection,
pregnancy)
 Hyperpyrexia, tachycardia, GI manifestations, cardiovascular
instability, mental status changes
 Diagnosis based on these clinical findings, not degree of
hyperthyroidism laboratory abnormalities (suppression of TSH,
elevation of T3/Free T4)

7. Thyroid Storm Goals of Treatment
 Treat/Identify trigger
 Symptomatic treatment of catecholamine overdrive
 Inhibition of new hormone synthesis
 Inhibition of hormone release
 Block peripheral conversion of T4 to T3

8. Treatment Summary
Overall Goal: Reduce circulation thyroid levels and control
symptoms
 Beta blockers; decreases adrenergic hyperactivity
 PTU (large amounts): prevents synthesis of the
hormone (also peripheral conversion to a lesser degree)
 Methimazole?
 Glucocorticoids: inhibit hormone production and
decrease peripheral conversion from T4 to T3.
 Sodium iodide solution (Lugol’s solution): High levels
of iodide will initially suppress release of thyroid
hormone
 Treat cardiac symptoms, fever and hypertension

9. Case #2
 34 y/o WF, PMHx of HTN, DM, Hypothyroidism
 Presents with complaint of abdominal pain and “not
acting right” per husband. Husband also notes her to be
“out of breath”
 HR 140, BP 128/74, RR 32, O2 sat 100% RA

10. Case #2
 Rectal Temp 101.0
 Accucheck “RR HI”
 Physical Exam

11. Case #2
 CBC- WBC 16 (6% Bands), H/H 15.2/45.8, platelets 420
 BMP Na 126, K 5.2, Cl 93, Bicarb 4, BUN 20, Cr 1.4, Glucose 590
 Lactate 3
 LFT’s WNL, Lipase normal
 U/A- 3 WBC, no RBC, nitrate neg, + Ketones, Spec Grav 1.030
 ABG- pH 7.05, pCO2 15, pO 2 160

12. Case#2- DKA
 Cornerstones of therapy
 Rehydration
 Turn off acidosis
 Find precipitating cause
 Maximize supportive care
 Bicarb?
 Intubation?

13. Case #3
 45 y/o WF, unknown PMHx, traveling from Virginia to
Daytona for “Biketoberfest”, totaled her motorcycle on a
I-95 off ramp.
 Intubated upon arrival in the trauma bay
 SDH, Grade 1 Splenic lac
 Have been unable to contact/locate family

14. Case #3
 Pt now in SICU, Hospital day 3
 During morning rounds at 2pm, it is now noted that the
patient’s BP is 65/40, HR 85, Temp 98.8, O2 sats 100%
 CBC- H/H 12.0/37 (13.2/40 at presentation), WBC 9
 BMP- Na 126, K 5.2, Cl 110, Bicarb 19, BUN 20, Cr 1.4, Glucose
60
 ABG- 7.42/110/40/25
 Diagnosis?

15. Adrenal Insufficiency/Crisis
 Pathophysiology
 Primary failure (adrenals)
 Deficiency of cortisol and aldosterone production
 Secondary failure (pituitary)
 Due to decreased production of ACTH
 Deficiency of only cortisol production
 Tertiary failure (hypothalamus)
 Decreased CRH release
 Abrubt cessation of glucocorticoids

16. Diagnosis
 Clinical diagnosis can be made, treated started empirically
 Acute Crisis
 Random cortisol
 <15 mcg/dL = diagnostic
 15-33 mcg/dL = indeterminant
 >33 mcg/dL = excludes
 ACTH stimulation test
 Rise of< 9 mcg/dL diagnostic

17. Treatment
 Dexamethasone (0.1 mg/kg) vs Hydrocortisone (100mg)