8 - Blue Flashcards
What is the etiology of adrenal insufficiency
Primary: Autoimmune Infection Vascular Metastatic disease Deposition disease Drugs
Secondary:
Pituitary failure
Glucocorticoids
Megestrol
Tertiary:
Hypothalamus failure
What are the signs and symptoms of adrenal insufficiency
Fatigue Weakness Anorexia N/V Weight loss Cutaneous & mucosal pigmentation Hypotension -> shock Hypoglycemia Decreased cold tolerance Dizziness, syncope EKG: decreased voltage, prolonged PR/QT intervals
What are the laboratory findings in adrenal insufficiency
Decreased: NA+, Cl-, HCO3
Hypoglycemia
Increased K+
+/- HyperCa2+
What is the cosyntropin stimulation test
Used to distinguish primary from secondary/tertiary disease
Give synthetic ACTH then measure cortisol at 0, 30, 60 mins
Baseline cortisol >15 ug/dl = N adrenal function
Cortisol rise >20 ug/do = N adrenal function
Abn test = primary disorder or chronic secondary disorder
What is the treatment for adrenal insufficiency
IV volume and sugar replacement (D5NS) Acute: Dex 4mg + hydrocortisone 100mg q6h until condition stabilizes Chronic: Fludrocortisone + hydrocortisone
How can iatrogenic adrenal suppression occur?
If supplemental corticosteroids are given over weeks to months
How long does it take the pituitary to become responsive again after adrenal suppression occurs
2-3 months to become responsive again
6-9 months for cortisol levels to normalize after d/c exogenous cortisol
What are the indications for stress dosing steroids?
Supraphysiologic steroid doses for > 1 week in past year
Known adrenal insufficiency
What is the stress dose of steroids?
1st pre-op dose = 300 mg hydrocortisone /day x24hrs
Rapid taper over 72 hours
What are the various types of hypothyroidism
Primary - Thyroid gland (Hashimotos, iodine deficiency, surgery, radiation, amiodarone, recovery phase thyroiditis)
Secondary - pituitary
Tertiary - hypothalamus
Thyroid hormone resistance - peripheral tissues
What are the precipitating factors for hypothyroidism
General anaesthesia
Cold exposure
Infection
Narcotic use
How does hypothyroidism present
Hypothermia Hypotension not responding to fluids or pressers Hypoventilation Obtundation Myxedema Coma Psychosis Increased digoxin toxicity
What do labs look like in hypothyroidism
Increased TSH Decreased thyroxine Hyponatremia Hypoglycemia Increased cholesterol Increased CPK Increased AST increased LDH
What is the management of hypothyroidism
300 mg hydrocortisone to avoid precipitating addisonian crisis
Levothyroxine - PO for mild disease
Thyroxine IV if myxedema coma
What is the DDx for hyperthyroidism
Graves Toxic multinodular goitre Thyrotoxic phase of subacute thyroiditis Toxic adenoma TSH secreting tumour Ectopic thyroid production Fictitious hyperthyroidism
