Transcript
Endocrine EmergenciesWayne Triner, DO, MPHEmergency Medicine
A 24 year old female presents with three days of progressive alteration of mental status. Today she was found by her partner to be highly anxious and seemingly with paranoid delusions. There is a history or prior alcohol use. She has not been at work as an artist (potter) for the past 4 days.PMHx: RA, AsthmaExam:Agitated, diaphoretic, shifting in bed, Unintelligible speech. 402, 136, 40, 132/68HEENT, Neck, Lungs: normalHeart: tachy, regular, 2/6 systolic ejection murmurAbd: silent, non-distended, non-tenderNeuro: mental status as described, non-focal, fine tremorExt: no edema, no marks, no hot jointsDerm: pink, moist, no rash
A 42 year old female presents with three days of progressive alteration of mental status characterized as somnolence and intermittent anxiety. There is a history of prior alcohol use. She has not been at work as an artist (potter) for the past 4 days.PMHx: RA, AsthmaExam:Agitated, shifting in bed, Unintelligible speech. 342, 52, 40, 106/70HEENT, Neck, Lungs: normalHeart: tachy, regular, 2/6 systolic ejection murmurAbd: silent, non-distended, non-tenderNeuro: mental status as described, non-focalExt: “brawny” edema on legs, no marks, no hot jointsDerm: pink, moist, no rash
A 46 year old female presents with three days of progressive alteration of mental status characterized as somnolence and intermittent anxiety. There is a history of prior alcohol use. She has not been at work as an artist (potter) for the past 4 days.PMHx: RA, AsthmaExam:Agitated, shifting in bed, Unintelligible speech. 342, 52, 40, 106/70HEENT, Neck, Lungs: normalHeart: slow, regular, 2/6 systolic ejection murmurAbd: silent, non-distended, non-tenderNeuro: mental status as described, non-focalExt: no edema, no marks, no hot jointsDerm: pink, moist, no rash
A 24 year old male presents with three hours of progressive alteration of mental status characterized as highly aggitated. There is a history of prior alcohol and illicit substance use. He was encountered by police and “Tazer’d”. He is restrained, face-down on the ambulance gurney. PMHx: RA, AsthmaExam:Agitated, diaphoretic, shifting in bed, Unintelligible speech. 402, 184, 40, 236/130HEENT, Neck, Lungs: normalHeart: tachy, regular, 2/6 systolic ejection murmurAbd: silent, non-distended, non-tenderNeuro: mental status as described, onset of seizure upon arrivalExt: no edema, no marks, no hot jointsDerm: pink, moist, no rash
Anxious, Delirious, Altered
Hyperadrenergic / Hypermetabolic State
Elevated blood pressure
Tachycardia
Delerium
Hyperpyrexia
Causes
• Intoxication• Psychosis• Endocrine
Excited Delirium
Hyperthyroidism
Subclinical Hyperthyroid
Hyper-thyroid
Thyro-toxicosis
Thyroid Storm
Suppressed TSHNormal T4
Suppressed TSHElevated T4
Subtle Symptoms
Suppressed TSHElevated T4
Dominant Symptoms
Suppressed TSHElevated T4
Severe SymptomsAltered Mental Status
Thyroid Storm (crisis)
• Dx: Hyperthyroid with altered mental status• Generally with hyperpyrexia
• Most common in 20’s and 30’s• 4:1 female to male
• Incidence unknown• However, thyrotoxicosis may effect 2% of women• Small percentage of whom experience Thyroid Storm
• Many Causes• Precipitated by;
Sepsis Thyroid traumaExogenous TH Iodine exposure“Hot nodule” Protein displacement (ASA, furosamide, NSAIDs)Surgery
Important Findings Thyrotoxicosis
Symptoms SignsNeuroPsych Anxiety
Nervousness / AgitationComa
TremorPeriodic paralysisMuscle wastingHyperreflexia
Endocrine OligomennorheaDecreased libido
Gynecomastia
GI Hypermotility
CardioVasc PalpitationsChest painDyspnea
S. Tach (40%)A Fib (20%)High output failure
Derm Hair loss Moist skinPre-tibial myxedema
Laboratory and Imaging
• Increased T4 / Decreased TSH
• Increased Free T3 / T4 ratio
• Likely of thyroid origin
• Hyperglycemia• Adrenocortical dysfunction• Increased production• Increased metabolism• Reduced adrenal response to
ACTH Stim test
• Thyroid ultrasound• Increased vascularity• Nodules• Normal
Thyroglobulin Synthesis
Iodination & Conjugation
Proteolysis to T3 & T4
Secretion
Peripheral Conversion of T4 to T3
Cellular Effect
Thyrotoxicosis/Storm Treatment
• Supportive care• Controlling adrenergic effects
• Stop synthesis of new T4 & T3
• Stop release of stored T4 & T3
• Preventing peripheral conversion of T4 to T3
• Ventilatory support• Thermoregulation• Hemodynamic support• Identify and treat
underlying cause
• Propranolol (β1 & β2)ONLY 1 Hr. FOLLOWING PTU• Iodine • SSKI• Lugol’s soln
• PTU• Hydrocoritsone
PTU• Short duration of
action• Hepatotoxic• Prevents conversion
of T4 to T3Methimizole• Does not impact T4
to T3 conversion
Thyrotoxicosis/Storm Treatment
1. β-Blocker• Propanolol• Esmolol
2. PTU or methimizole
3. Hydrocortisone
4. Iodine*• SSKI • Lugol’s Solution
5. Generally, definitive control of hyperthyroidism isn’t considered until thyrotoxicosis/storm is controlled for at least six weeks.
A 24 year old female presents with three days of progressive alteration of mental status. Today she was found by her partner to be highly anxious and seemingly with paranoid delusions. There is a history or prior alcohol use. She has not been at work as an artist (potter) for the past 4 days.PMHx: RA, AsthmaExam:Agitated, diaphoretic, shifting in bed, Unintelligible speech. 402, 136, 40, 132/68HEENT, Neck, Lungs: normalHeart: tachy, regular, 2/6 systolic ejection murmurAbd: silent, non-distended, non-tenderNeuro: mental status as described, non-focal, fine tremorExt: no edema, no marks, no hot jointsDerm: pink, moist, no rash
A 42 year old female presents with three days of progressive alteration of mental status characterized as somnolence and intermittent anxiety. There is a history of prior alcohol use. She has not been at work as an artist (potter) for the past 4 days.PMHx: RA, AsthmaExam:Agitated, shifting in bed, Unintelligible speech. 342, 52, 40, 106/70HEENT, Neck, Lungs: normalHeart: tachy, regular, 2/6 systolic ejection murmurAbd: silent, non-distended, non-tenderNeuro: mental status as described, non-focalExt: “brawny” edema on legs, no marks, no hot jointsDerm: pink, moist, no rash
A 46 year old female presents with three days of progressive alteration of mental status characterized as somnolence and intermittent anxiety. There is a history of prior alcohol use. She has not been at work as an artist (potter) for the past 4 days.PMHx: RA, AsthmaExam:Agitated, shifting in bed, Unintelligible speech. 342, 52, 40, 106/70HEENT, Neck, Lungs: normalHeart: slow, regular, 2/6 systolic ejection murmurAbd: silent, non-distended, non-tenderNeuro: mental status as described, non-focalExt: no edema, no marks, no hot jointsDerm: pink, moist, no rash
A 24 year old male presents with three hours of progressive alteration of mental status characterized as highly aggitated. There is a history of prior alcohol and illicit substance use. He was encountered by police and “Tazer’d”. He is restrained, face-down on the ambulance gurney. PMHx: RA, AsthmaExam: Agitated, diaphoretic, shifting in bed, Unintelligible speech. 402, 184, 40, 236/130HEENT, Neck, Lungs: normalHeart: tachy, regular, 2/6 systolic ejection murmurAbd: silent, non-distended, non-tenderNeuro: mental status as described, onset of seizure upon arrivalExt: no edema, no marks, no hot jointsDerm: pink, moist, no rash
Excited Delirium
Fatal Cases• 95% male• Mean age 36• Almost all engage law
enforcement• Resisted struggle• TASER use• Restraint
Commonalities• Face-down restrain• Period of “giving-up”• Inability to resuscitate• Basil ganglion lack of
dopamine(exhaustion hypothesis)
ExDS Management
• Restrain supine• Benzodiazepines• Constant, direct observational monitoring• Control hyperthermia• Anticipate acidosis
A 24 year old female presents with three days of progressive alteration of mental status. Today she was found by her partner to be highly anxious and seemingly with paranoid delusions. There is a history or prior alcohol use. She has not been at work as an artist (potter) for the past 4 days.PMHx: RA, AsthmaExam:Agitated, diaphoretic, shifting in bed, Unintelligible speech. 402, 136, 40, 132/68HEENT, Neck, Lungs: normalHeart: tachy, regular, 2/6 systolic ejection murmurAbd: silent, non-distended, non-tenderNeuro: mental status as described, non-focal, fine tremorExt: no edema, no marks, no hot jointsDerm: pink, moist, no rash
A 64 year old female presents with three days of progressive alteration of mental status characterized as somnolence and intermittent anxiety. There is a history of prior alcohol use. She has not been at work as an artist (potter) for the past 4 days.PMHx: RA, AsthmaExam:Agitated, shifting in bed, Unintelligible speech. 342, 42, 10, 106/70, SpO2 .86HEENT, Neck, Lungs: normalLungs: bi-basilar cracklesHeart: slow, regular, 2/6 systolic ejection murmurAbd: silent, distended, non-tenderNeuro: mental status as described, non-focalExt: “brawny” edema on legs, no marks, no hot joints, dry skin
A 46 year old female presents with three days of progressive alteration of mental status characterized as somnolence and intermittent anxiety. There is a history of prior alcohol use. She has not been at work as an artist (potter) for the past 4 days.PMHx: RA, AsthmaExam:Agitated, shifting in bed, Unintelligible speech. 342, 52, 40, 106/70HEENT, Neck, Lungs: normalHeart: slow, regular, 2/6 systolic ejection murmurAbd: silent, non-distended, non-tenderNeuro: mental status as described, non-focalExt: no edema, no marks, no hot jointsDerm: pink, moist, no rash
A 24 year old male presents with three hours of progressive alteration of mental status characterized as highly aggitated. There is a history of prior alcohol and illicit substance use. He was encountered by police and “Tazer’d”. He is restrained, face-down on the ambulance gurney. PMHx: RA, AsthmaExam:Agitated, diaphoretic, shifting in bed, Unintelligible speech. 402, 184, 40, 236/130HEENT, Neck, Lungs: normalHeart: tachy, regular, 2/6 systolic ejection murmurAbd: silent, non-distended, non-tenderNeuro: mental status as described, onset of seizure upon arrivalExt: no edema, no marks, no hot jointsDerm: pink, moist, no rash
Na 122
K 4.3
NaHCO3 36
Hgb 105
Labs and Findings
Hypothyroidism
• General reflection of organ system slowing• Accumulation of glycosaminoglycans• Derm changes
• Many underlying causes• Autoimmune
GravesHashimoto’s
• Iatrogenic
• Primary / Secondary
None of this matters to us
Hypothyroidism
SubclinicalHypothyroid
Hypo-thyroid
Myxedema Coma
Elevated* TSHNormal T4
Elevated* TSHReduced T4
+Symptoms
Elevated* TSHReduced T4
Severe Symptoms40% Mortality
Myxedema Coma
Case Definition
Severe hypothyroidism• Alteration of mental
status• Hypothermia• Bradycardia
Diagnostic Clues
• Thyroid ablation or thyroidectomy
• Often insidious Slow progressive reduced mental status
• Hypothermia• Hypoventilation• Hyponatremia• Hypo…
Myxedema Coma Treatment
• Consider the DiagnosisTSH & T4
• Supportive• Thermoregulation• Ventilation• Empirically treat adrenal
insufficiencySpot cortisol level
• Seek and treat SEPSIS• Avoid over resuscitation
• Specific
Thyroid ReplacementT4 “physiologic” conversion to T3
T3 rapid onset of action
T4 & T3
A 24 year old female presents with three days of progressive alteration of mental status. Today she was found by her partner to be highly anxious and seemingly with paranoid delusions. There is a history or prior alcohol use. She has not been at work as an artist (potter) for the past 4 days.PMHx: RA, AsthmaExam:Agitated, diaphoretic, shifting in bed, Unintelligible speech. 402, 136, 40, 132/68HEENT, Neck, Lungs: normalHeart: tachy, regular, 2/6 systolic ejection murmurAbd: silent, non-distended, non-tenderNeuro: mental status as described, non-focal, fine tremorExt: no edema, no marks, no hot jointsDerm: pink, moist, no rash
A 64 year old female presents with three days of progressive alteration of mental status characterized as somnolence and intermittent anxiety. There is a history of prior alcohol use. She has not been at work as an artist (potter) for the past 4 days.PMHx: RA, AsthmaExam:Agitated, shifting in bed, Unintelligible speech. 342, 42, 10, 106/70, SpO2 .86HEENT, Neck, Lungs: normalLungs: bi-basilar cracklesHeart: slow, regular, 2/6 systolic ejection murmurAbd: silent, distended, non-tenderNeuro: mental status as described, non-focalExt: “brawny” edema on legs, no marks, no hot joints, dry skin
A 46 year old female presents with three days of progressive alteration of mental status characterized as somnolence and intermittent anxiety. She has been vomiting and expressing abdominal pain for 24 hours. There is a history of prior alcohol use. She has not been at work as an artist (potter) for the past 4 days.PMHx: Asthma Meds unknownExam: Agitated, shifting in bed, Unintelligible speech. 382, 136, 40, 86/70HEENT, Neck, Lungs: normalHeart: slow, regular, 2/6 systolic ejection murmurAbd: silent, non-distended, diffusely tenderNeuro: mental status as described, non-focalExt: no edema, no marks, no hot jointsDerm: pink, moist, no rash
A 24 year old male presents with three hours of progressive alteration of mental status characterized as highly aggitated. There is a history of prior alcohol and illicit substance use. He was encountered by police and “Tazer’d”. He is restrained, face-down on the ambulance gurney. PMHx: RA, AsthmaExam:Agitated, diaphoretic, shifting in bed, Unintelligible speech. 402, 184, 40, 236/130HEENT, Neck, Lungs: normalHeart: tachy, regular, 2/6 systolic ejection murmurAbd: silent, non-distended, non-tenderNeuro: mental status as described, onset of seizure upon arrivalExt: no edema, no marks, no hot jointsDerm: pink, moist, no rash
Her partner arrives and reports that she is a fragile asthmatic and has been to several EDs over the course of the past year. She has been on Prednesone almost continuously for 10 months.
Adrenal Crisis
• Widely variable presentation• Largely dependent upon etiologies • Primary, secondary, tertiary
• Wide range of etiologies• Precipitating event
Diagnostic Clues
Findings
• Physical Exam• Laboratory • Hyponatremia 85%
• Neuro-psych
The Traps
• Surgical referral for abd pain and fever
• Failure to recognize• Failure to carry out
diagnostic tests
Approach to Management
• Fluid resuscitation• Treat empirically with
dexamethasone• Seek provoking cause
• Short ACTH stim test1. Baseline serum cortisol
2. Co-syntropin® 250 mcg IV
3. 30 and 60 minute serum cortisol
• Normal outocome• 18-20 mcg/dl (500 nmol/L)
Endocrine EmergenciesWayne Triner, DO, MPHEmergency Medicine
top related