Endocrine

Question 1

Treatment of thyroid storm

Answer 1

Supportive care:

• benzos titrated for agitation
• hydrocortisone 200mg IV for relative adrenal insufficiency and block T4->T3
• propranolol 1mg-10mg titrated to block catecholamine surge

Block hormone synthesis
- PTU 1g blocks T4->T3

Iodine

• 1hr after PTU
• 5 drops lugols iodine (0.5mls)
• if allergy can give 1g Lithium

Seek and treat precipitant

Question 2

Thyrotoxicosis symptoms

Answer 2

CNS: agitation, delirium

CVS: tachycardia, arrhythmia, high output cardiac failure

Gastro: d+v, abdo pain, jaundice

Fever

FAT PIG

• fever
• altered mental state
• tachycardia
• precipitant
• increased cardiac output failure
• gastro symptoms

Raised T4/T3 and low TSH

Question 3

Myxoedema coma symptoms and signs

Answer 3

Hypothyroidism + hypothermia + mental state changes + precipitant

CNS: reduced GCS, hypoactive delirium, reduced/hung up Achilles reflex

CVS: bradycardia, hypotension, pericardial effusion

Hypothermia

Resp: resp failure, hypoventilation and hypercapnia, hypoxia, pleural effusion

Airway: macroglossia, laryngeal oedema, glottic oedema

Pre-tibial ‘woody’ myxoedema
Facial oedema

Question 4

Myxoedema coma treatment

Answer 4

High TSH, low T4/T3

Levothyroxine 100-500mcg IV bolus and 100mcg daily
- vasopressors won’t work until have thyroid hormone
Hydrocortisone 100mg IV if concern for adrenal insufficiency
IV fluid resus - often volume depleted