Metabolic

Question 1

Hyperthyroidism - basics and Symptoms

Answer 1

Elevated T3 and T4 (T3 is more active form)
Low TSH (< 0.001)
In secondary hyperthyroidism - can have normal or elevated TSH

Symptoms:
- Fever
- altered mental status
- Tachycardia
- tachypnea
- hypertension
- diarrhea
- weight loss

Question 2

Secondary Causes of Hyperthyroidism

Answer 2

TSH releasing tumors
TRH releasing tumors
Carcinoma
Hydatiforme moles
Amiodarone toxicity (3.5 months average from time of initiation to dx)
Sx
Trauma
Thyroid med OD
Iodine Load

Question 3

Thyroid storm / Thyrotoxicosis

Answer 3

Altered mental status
Tachycardia
Pyrexia
WITH end organ damage - TnT, LFTs, Cr

Ager > 65 - 1/3 will present with apathetic thyrotoxicosis (depression, heart failure, non-specific)

Question 4

Thyrotoxicosis Treatment

Answer 4

General:
- Supportive
- Trigger Reversal
- Thyroid Specific:

5 B’s
- Block Synthesis: PTU (safe in 1st trimester) vs Methimazole (2nd/3rd trimester)
Methimazole - 40 mg load and 20 mg Q4
PTU 200 mg IV Q4
- Block Release: Methimazole + Iodine dosing (SSKI 1-2 drops TID)
- Block Beta: Symptomatic Tx only. Can cause deterioration and death if underlying HF.
- Block Conversion: T4-T3. Steroids: Hydrocort 300 mg IV then 100mg IV TID
- Block Hepatic Circulation: Cholestyramine, 4g QID until resolved.

Question 5

Hypothyroid / Myxedema Work-up Demographics / Mgmt

Answer 5

TSH
FT3, FT4
Cortisol level
ECG, POCUS/ECHO

PRESENTATION: Slow, old, cold, puffy (Non-pitting edema).

Mgmt: IV levothyroxine (100 mcg IV), hydrocort / stress dose steroid, rewarm, fluids and pressors to temporize. Treat underlying cause.

DDx: Low and slow toxidrome, sepsis, structural issues

Question 6

DKA Diagnostic Criteria

Answer 6

pH < 7.3 arterial
Bicarb < 15
AG > 12
Positive serum or urine ketones

Question 7

DKA Mgmt

Answer 7

Fluid Resus 2-3 L
Replete K > 3.5
DKA order set (0.1 U/kg /hr)
Consider give bicarb if HCO < 10 and and peri-arrest
BG < 15

Follow Algorithm

Treat underlying cause

Question 8

HHS

Answer 8

Not as acidotic
Lower ketones
+++++ Volume deficit
Osm > 320 mmol/kg
Gluc > 33.3
K+ Significant losses

Treat to Osms

Question 9

Euglycemic DKA

Answer 9

AGMA in a sick patient with DM
- Carbohydrate
Dx:
BG 11-14, pH < 7.3, bicarb < 18

Give fluids and glucose up front

Question 10

Adrenal Insufficiency

Answer 10

Primary: Cortisol, DHEA and Aldosterone Down (Electrolyte abnormality)

Secondary: Aldo not affected (RAAS) system so electrolytes can be normal.

Think about it:
- Adrenal Insufficiency + Stressor
-

Question 11

Adrenal Insufficiency

Answer 11

Primary: Cortisol, DHEA and Aldosterone Down (Electrolyte abnormality)

Secondary: Aldo not affected (RAAS) system so electrolytes can be normal.

Think about it:
- Adrenal Insufficiency + Stressor
- Infection, preg, surgery, med changes, infarction

Acute: Waterhouse-Friderichsen Syndrome (DIC), Sheehan’s (Pregnancy), pituitary apoplexy etc
- Infections: TB, HIV and fungal infections.

Dose Pred: >7.5 mg x 3 weeks can cause adrenal suppression

Tx:
- Hydrocort: 100 mg Hydrocortison IV or IM with 200 mg Hydrocort / 24h continuous infusion or 50 mg Q6H
- Rehydration usually 3-4 L

Stress dose = 3 x home dose.

If suspected AI - give dex 4-6 mg once if want ACTH stim test.

Question 12

Hyperthyroid - Thyrotoxicosis

Answer 12

Whom to consider:
- New a. fib
- Hot and Crazy
- Known hyperthyroid
- Hyperthermia > 40
- Sepsis without source of infection
- New onset delirium

Precipitants: Same as rest - medication non-compliance, factitious

Symptoms:
- High output heart failure, tachy, a.fib

Labs: hyperK, Hyponatremia
- Consider Adrenal Insufficiency

Treatment:
- Beta Blocker (Esmolol may actually be safest - if significant HF) 20-40 mg Q6
- PTU
Wait and
- Steroid (100 mg Hydrocort)
- Iodine (Woiff-Chaikoff turns thyroid off. Jod-Basedo in overactive thyroid can lead to increased T3/T4 if not supressed prior to giving Iodine)
Methimazole - contraindicated in 1st trimester pregnancy choanal atresia in utero. Less hepatotoxicity