Endocrine Emergencies II

Question 1

• Hypothyroidism + hypothermia, hypotension, AMS
• Clinical diagnosis for patients with pre-existing hypothyroidsm
• sxs: hypothermia, weight gain, hyporeflexia, bradycardia, hypoventilation, pleural effusions on CXR, facial swelling, onycholysis
• precipitated by infection, cold exposure, trauma, MI, CVA, surgery, medications like BB, narcotics, sedatives

elderly women in winter months

Answer 1

Myxedema coma

Question 2

treatment of myxedema coma?

Answer 2

• D5NS (Hypoglycemic)
• passive re-warming with blankets
• broad spectrum antibiotics (sepsis mimic)
• hydrocortisone 100mg IV
• levothyroxine IV 4mcg/kg loading dose in the ED

Question 3

• Thyrotoxicosis + fever, tachycardia, AMS
• clinical diagnosis for patients with pre-existing hyperthyroidism
• most commonly precipitated by infection, other causes include amiodarone or any iodine containing medication, DKA, HHS
• doorway assessment should tell you these patients are toxic, febrile, agitated and sick

Answer 3

Thyroid storm

Question 4

treatment of thyroid strom?

Answer 4

• D5NS
• PTU (propthiouracil) 600-1000mg PO or PR
• beta blockade with propranolol (non specific BB) or esmolol
• external cooling
• tyelenol for fever (avoid ASA)

Question 5

• hypotension that does NOT respond to fluids and pressors
• clinical diagnosis for anyone who depends on steroids (> 10mg QD for > 3 weeks) and is hypotensive
• SX: N/V, weakness, confusion, ALOC, abdominal pain
• if specifically from adrenal hemorrhage: back pain, fever, hyperkalemia, azotemia, hyponatremia.
• labs: serum cortisol level normal sepsis work up
• Hyperkalemia, hyponatremia

Answer 5

Adrenal crisis

Question 6

precipitants of adrenal crisis

Answer 6

• infectious: meningococcemia (causes hemorrhage into adrenals, called waterhouse-friderichsen syndrome) HIV, TB, sepsis
• Adrenal hemorrhage: supratherapeutic INR, trauma, spontaneous
• autoimmune disease: sarcoid, lupus
• pituitary dysfunction: head trauma, post-op pituitary surgery, necrosis of a benign tumor, sheehan syndrome
• wtihdrawl of chronic steroid use
• etomidate: common medication used for procedural sedation and anesthesia

Question 7

tx for adrenal crisis?

Answer 7

• ABCs
• D5 NS
• hydrocortisone IV 100-300mg

Question 8

• serum sodium level < 135mm/L
• asymptomatic if chronic
• Edema
• N/V
• muscle cramps

If severe

• altered mental status
• seizures
• coma

Development of symptoms is related more to the rate of change than to the absolute values

Answer 8

hyponatremia

Question 9

tx of hyponatremia?

Answer 9

depends on the cause and overall volume status, as well as chronicity

• SIADH, phychogeneic polydipsia, beer potomania, renal failure, acute adrenal insufficiency

As a general rule… GO SLOW

if they have chronic hyponatremia

• if they have zero neuro sxs, you do not have to correct right away

Question 10

• Serum sodium level > 150mm/L
• generally become symptomatic > 158
• restlessness, irritability
• ataxia
• hyperreflexia, twitching, spasticity
• seizure, coma death
• MC seen in ED due to volume loss such as doinf the ironman

Answer 10

Hypernatremia

Question 11

tx of hypernatremia?

Answer 11

cornerstone of treatment is volume repletion

• start with 1L NS bolue, in acute hypernatremia, its okay to correct this fairly rapidly
• if they had any neuro sxs or their Na was > 155mEq at arrival- admit
• if chronic hypernatremia, reduction should be slow

Question 12

• Fatigue, generalized weakness, malaise
• muscle cramps, hyporeflexia, paresthesias
• EKG changes (t wave flattening, U waves in precordial leads, QT prolongation, tachy arrhthmias degrading into torsades
• Precipitated byGI losses (n/v/d) diuretics, heavy exercise/ sweating/ heat stroke

Answer 12

Hypokalemia

Question 13

tx for hypokalemia?

Answer 13

work up

• ECG, keep on cardiac monitor
• mag and phos levels
• renal function
• cbc

Treat

• for every 10mEq replaced serum K will increase by . 1
• PO k if they only need a few mEQ
• IV K if they are below 3.0 mEq

Question 14

• fatigue, weakness, malaise
• N/V
• paresthesias, weakness, cramps
• palpitations/chest pain
• death
• Precipitated by: hemolysis, renal failure, heavy exercise, k sparing diuretics, ace inhibitors, bactrim

Answer 14

Hyperkalemia

Question 15

tx of hyperkalemia?

Answer 15

C BIG K DIE

• Ca gluconate
• beta agonists: albuterol, upregulates shift of K into cells
• Insulin- upregulates shift of K into cells
• glucose when give glucose, give insuling
• kaylexate
• dialysis
• (+/- lasix, often the hospitalist will ask for this as well)

Question 16

Neuromuscular excitability

• capopedal spasm
• tetany
• seizure, altered mental status
• trousseau’s sign (carpal spasm with the BP cuff blown up for >3 minutes)
• chvosteks sign (facial spasm with light tap over the face just in front of the ear)

Cardiovascular

• prolonged Qtc segment
• bradycardia
• 3rd degree block

Answer 16

Hypocalcemia