Endocirne 2 Flashcards
myxedema crisis
severe multi organ decompensation in a HYPOTHYROID pt
mental status changes, HoTN, HoThermia
myxedema crisis clinical features
bradycardia HoTN HoThermia AMS Coma
may have infection w/o signs due to masking by bradycardia and HoThermia
clinical shock, systolic <100 MAY present in coma
neuro exam finding myxedema crisis
delayed DTRs dementia psychosis paresthesia depression poor memory confusion ataxia
cardiopulmonary exam findings myxedema crisis
angina bradycardia distant heart sounds low voltage ECG pericardial effusion cardiomyopathy Hoventilation
derm findings myxedema crisis
dry skin hair loss non pitting edema facial swelling ptosis macroglossia periorbital edema
lab eval myxedema crisis
primary hypothyroid
high TSH
low T3/T4
lab eval myxedema crisis
secondary hypothyroid
low TSH
Low T3/T4
myxedema crisis tx
initiate tx without waiting for lab confirmation
- support tx
- thyroid hormone replacement
- identification and tx of precipitating factors
supportive care in myxedema crisis
ABCD IV dextrose tx vasopressors hypothermia rewarming steroids
thyroid replacement myxedema crisis severe
T3 +/- T4
caution in pts with myocardial compromise
myxedema crisis thyroid replacement IV drugs
levothyroxine (T4) OR liothryonine or triodothyronine (T3)
T3- no more than 10 micrograms for elderly or CAD
myxedema crisis disposition
high mortality rate
ICU admission
elderly and myxedema crisis
age
cardiac comorbidities
thyroid replacement = WORSE outcome
T4 and T3 avoiding for arrhythmia (std doses)
start with HALF normal dose
cardiac instability myxedema crisis
T4 is better for cardiac safety
thyroid hormone fxn
increase metabolic rate, HR, ventricle contractility, muscle and CNS excitability
T3 and T4 are 2 types (T4 more common, T3 more potent)
thyrotoxicosis
excess circulating thyroid hormone (any cause)
thyroid storm
extreme thyrotoxicosis
acute, severe life threatening state of thyrotoxicosis
cause of thyroid storm
untreated hyperthyroidism surgery infecton trauma acute iodine load childbirth exogenous thyroid hormone One Direction
precipitants of thyroid storm
systemic insult
CV insult
unknown
MC overall is infection
thyroid storm clinical features
fever
tachycardia
ams
thyroid storm palpitations
tachycardia
direct inotropic and chronotropic effects of thyroid hormone
increased contractility and output
AFib
water hammer pulse
CNS findings of thyroid storm
anxiety agitation delirum stypor coma seizure
thyroid lab evaluation
not always acutely elevated when transition from thyrotoxicosis occurs
low TSH and elevated T4 confirms diagnosis
order of tx for thyroid storm
thionamide must be initiated 1 hr BEFORE iodine
tx list of thyroid storm
- supportive care (airway, fever control. nutrition, BB)
- inhibit hormone production
- inhibit hormone release
- B-adrenergic R blockade
- inhibition of T4 conversion
pts are admitted to ICU
list of thionamide
block production
- PTU
- Methimazole
PTU preferred (blocks T4 conversion)
prevention of hormone release (list)
- Lugol solution
2. potassium iodide (SSKI)
BETA-adrenergic R blockers in thyroid storm
- propanolol
- esmolol
- reserpine
- guanethidine
how do we block peripheral T4-T3 conversion in thyroid storm
PTU and glucocorticoids
Hydrocortisone, Dexamethasone
amiodarone and thyroid storm
precipitant of thyroid storm
chronic use of amiodaron causes hypothyroid or thyrotoxic state in 20-30% of patients
hormones secreted by adrenal gland
cortisol
alderstone
gonadocorticoids
types of adrenal insufficiency
primary/Addison’s dz (decreased cortisol and aldosterone)
secondary: central dysfunction, decreased ACTH production, ONLY decreased cortisol
adrenal crisis
exacerbation of adrenal insufficiency due to
- increased demand (infection, trauma, MI..)
- decreased cortisol supply
adrenal gland fails to mount a stress response
occurs in primary or secondary
major stressors adrenal crisis
acute MI sepsis sx truama other illness
MC cause of adrenal crisis
rapid withdrawal of steroids in pt with adrenal atrophy secondary to long term steroid administration
clinical features of adrenal crisis
HoTN refractory to pressers syncope dehydration hyperpigmentation abdominal pain, n/v
when to suspect adrenal crisis
unexplained HoTN in pts w/:
long term glucocorticoid therapy + acute stress event, known dz
rapid withdrawal or non compliance with steroid
AIDs pt
severe head trauma
severe infection
labs adrenal crisis
ACTH
random cortisol level
aldosterone and renin levels
underlying pathology
tx of adrenal crisis
- IV fluids (5% dextrose in NS) correct Hoglycemia, HoNatremia
- Steroids (hydrocortisone)
- Vasopressors
adrenal supplementation in adrenal crisis
minor stress
25 mg/d of hydrocortisone
I.e. mild fever, n/v
adrenal supplementation in adrenal crisis
moderate stress
50-75 mg/D
PNA, pancreatitis
adrenal supplementation in adrenal crisis
severe stress
100-150 mg of hydrocortisone for 1 to 3 days
sepsis, shock
