Endocrine emergencies

Question 1

Adrenal crisis

Answer 1

Precipitants: Infection, sudden stopping of chronic glucocorticoid therapy, failure to increase glucocorticoid dose during intercurrent illness, after trauma, during surgery requiring GA.

Symptoms: Fever, confusion, hypotension, pre-renal failure, hypoNa, HyperK, Altered pigmentation (primary hyperpigmentation, secondary pale)

Abdominal pain, nausea, vomiting, weight loss.

Question 2

Pituitary apoplexy

Answer 2

Bitemporal hemianopia is common presentation.

Is suspected then ensure haemodynamic stability, assessment and management of fluid/electrolyte balance, consider hydrocortisone therapy.

Urgent biochemical and endocrine assessment (FBC, U&E, LFT, clotting screen, IGF-1, GH, prolactin, TSH, T4, LH, cortisol, testosterone, oestradiol)

Urgent MRI to confirm diagnosis

Liaise with regional endocrine and neurosurgical teams after dx confirmed.

If severely reduced VA, severe and persistent or deteriorating VF and level of consciousness then consider surgical management.

Question 3

Myxoedema coma

Answer 3

Symptoms: Goitre, Neck scar (prev surgery), Airway obstruction, respiratory depression, hypothermia, altered mental state: confusion, psychosis, coma.
Cardiomegaly, bradycardia, hypotension, abdominal pain, distension, constipation, hyporeflexia, dry skin.

ECG- Bradycardia, widespread T wave inversion, low voltage complexes.

Management: supportive measure, assess airway adequacy- check ABG, consider intubation, ventilation.

Passively warm.

Take blood for T4, TSH, cortisol, U&E, blood cultures.

If hypona consider fluid restriction if mild or short term saline if severe.

Treat hypotension with IV fluids

Correct hypoglycaemia if present with IV glucose

Administer IV hydrocortisone (50mg every 6hrs)

Give broad spectrum abx

Give T4 IV or via NG tube. If no improvement within 1-3 days consider adding T3.

Question 4

Thyroid storm

Answer 4

Symptoms of thyroid storm: Agitation, confusion, opthalmopathy, pyrexia, goitre, jaundice, cardiac failure, tachycardia, arrhythmias, diarrhoea, vomiting, tremor, dehydration.

ECG shows AF with rapid ventricular response

CXR shows pulmonary oedema

Management:
Administer IV fluids
Check Ft4, Ft3, TSH, blood cultures, U&E

PCM for fever. Chlorpromazine if agitation.

If vomiting pass NG tube

Treat tachycardia with propranolol
Consider high dose digoxin
Anticoagulate if atrial arrhythmia

Administer IV hydrocortisone 50mg every 8hrs

Administer PTU or potassium iodide after 4hrs.

Consider broad spectrum abx.

Question 5

Acute Hyponatraemia

Answer 5

Symptoms: Cerebral oedema, raised ICP (Headaches, vomiting, confusion, drowsiness, seizures, encephalopathy)

Acute if < 48hrs. Profound if Na < 125, symptomatic

Assess for signs of cerebral oedema/raised ICP.
Headache, confusion, drowsiness, coma, encephalopathy, seizures.

Move to high dependency area with monitoring

Give 150ml 3% saline IV over 20mins

Recheck sodium after 20mins. Give further 150ml 3%saline IV over 20mins until Na has increased by 5mmol/l

Recheck sodium at 6,12,24,48hrs

Establish cause

Diagnosis specific tx.

Question 6

Severe hypercalcemia

Answer 6

Symptoms: Confusion, coma, thirst, HTN, Pancreatitis, peptic ulceration, anorexia, nausea, constipation.
Cardiomyopathy, Shortened QT, arrhythmias, renal impairment, Nephrolithiasis, Nephrocalcinosis, polyuria.

Severe hypercalcemia >3mmol/l

Assess possible underlying cause and check fluid balance.

Check ECG (shortened QT and arrhythmias)
Check adjusted calcium, phosphate, PTH and U&E

Rehydrate with 0.9%saline upto 4-6L in 24hrs (caution in elderly/HF/RF/LF)

Administer 4mg zoledronic acid IV over 15mins

Monitor adjusted serum calcium levels.

Consider second line therapy if inadequate response
Calcitonin, prednisolone, cinacalcet, dialysis, parathyroidectomy.

Question 7

Acute hypocalcaemia

Answer 7

Symptoms: Seizures, Peri-oral numbness, positive trousseau’s sign, positive Chvostek’s sign, laryngospasm/stridor, muscular cramps, prolonged QT, risk of arrhythmias, carpopedal spasm and tetany, digital paraesthesia.

Management: 
Acute hypocalcaemia (symptomatic and/or adjusted calcium <1.9 mmol/L)

Assess for possible underlying causes

Check ECG (prolonged QT and arrhythmias)
Check adjusted calcium, phosphate, PTH, Vitamin D, Magnesium and U&Es.

Administer 10-20ml 100% calcium gluconate IV in 50-100mL 5% dextrose over 10 mins.

Repeat until patient asymptomatic
Commence calcium gluconate infusion
(dilute 100ml 10% calcium gluconate in 1 L 5% dextrose or 0.9% saline. Infuse at 50-100mL/hr)

Titrate infusion to adjusted calcium level

Correct hypomagnesaemia if present

Treat underlying cause.