Non – Diabetic Endocrine Emergencies

1. Non – Diabetic Endocrine Emergencies “What an emerg doc needs to know” Rob Hall PGY3 December 5th, 2002

2. WHY? Uncommon Potentially lethal Diagnostic dilemmas ED treatment may be life-saving Non – Diabetic Endocrine Emergencies

3. Outline

4. Objectives • How uncommon? • What defines thyroid storm, myxedemic coma, adrenal crisis? • What are the main clinical features? • When should these dx be considered? • What investigations are pertinent? • What is the emergency management? • When and how do you give stress dosing for chronic adrenal insufficiency?

5. 37 yo female Chest Pain and SOB Denies any PMHx Recent weight loss Sinus tach 130 Temp 40 Agitated Tremulous Case

6. CASE

7. NOT GOOD! CASE

8. Thyroid Storm

9. What is Thyroid Storm?

10. What is Thyroid Storm?Burch 1993

11. Etiology of Thyroid Storm Undiagnosed Undertreated (Grave’s disease or Mulitnodular toxic goiter) Acute Precipitant Thyroid Storm

12. 1% of all hyperthyroids Mortality 30% Precipitants Vascular Infectious Trauma Surgery Drugs Obstetrics Any acute medical illness Thyroid Storm

13. KEY FEATURES of Thyroid Storm • FEVER • TACHYCARDIA • ALTERED LOC • Features of underlying Hyperthyroidism • Weight loss, heat intolerance, tremors, anxiety, diarrhea, palpitations, sweating, CP, SOB • Goiter, eye findings, pretibial myxedema

14. When should you consider Thyroid Storm and what is the ddx? • Infectious: sepsis, meningitis, encephalitis • Vascular: ICH, SAH • Heat stroke • Toxicologic • Sympathomimetics, seritonin syndrome, neuroleptic malignant syndrome, Delirium Tremens, anticholinergic syndrome

15. Thyroid Testing TSH Free T4 Don’t need to order total T3/4, TBG, T3RU, FT3 Look for precipitant ECG CXR Urine Labs Blood cultures Tox screen ? CT head ? CSF INVESTIGATIONS

16. Thyroid Storm: Goals of Management • 1 - Decrease Hormone Synthesis • 2 - Decrease Hormone Release • 3 - Decrease Adrenergic Symptoms • 4 - Decrease Peripheral T4 -> T3 • 5 - Supportive Care

17. Decrease Hormonal Synthesis • Inhibition of thyroid peroxidase • Propylthiouracil (PTU) or Methimazole (Tapazole) • PTU is the drug of choice • PTU 1000 mg po/ng/pr then 250 q4hr • No iv form • Safe in pregnancy • S/E: rash, SJS, BM suppression, hepatotoxic • Contraindications: previous hepatic failure or agranulocytosis from PTU

18. Decrease Hormone Release • Iodine or lithium decreases release from hormone stored in colloid cells • MUST not be given until 1hr after PTU • Potassium Iodide (SSKI) 5 drops po/ng q6hr • Lugol’s solution 8 drops q6hr

19. Decrease Adrenergic Effects • Most important maneuver to decrease morbidity/mortality • Decreases HR, arrythmias, temp, etc • Propranolol 1 – 2 mg iv q 10 min prn • Propranolol preferred over metoprolol • Contraindications to beta-blockers • Reserpine 2.5 – 5.0 mg im q4hr • Guanethidine 20 mg po q6hr • Diltiazem

20. Decrease T4 -> T3 • Corticosteriods • PTU and propranolol also have some effect • Dexamethasone 2 – 4 mg iv • Relative or absolute adrenal insufficiency also common

21. Supportive Care • Fluid rehydration • Correct electrolyte abnormalities • Control temperature aggressively • Ice, cooling blanket, tylenol, fans • Search for precipitant • Think vascular, infectious, trauma, drugs, etc

22. PTU PROPRANOLOL POTASSIUM IODIDE STERIODS SUPPORTIVE CARE P3S2 Summary of Management

23. Apathetic Hyperthyroidism • Elderly (can be any age) • Altered LOC, Afib, CHF • Minimal fever, tachycardia • No preceeding hx of hyperthyroidism except weight loss • More COMMON than thyroid storm • Check TSH in any elderly patient with altered LOC, psych presentation, Afib, CHF

24. Outline

25. What is Myxedemic Coma? • Myxedema = swelling of hands, face, feet, periorbital tissues • Myxedemic coma = decreased LOC associated with severe hypothyroidism • Myxedemic coma/Myxedema generally used to mean severe hypothyroidism

26. Hypothyroidism Myxedemic Coma Myxedemic Coma

27. Etiology of Myxedemic Coma Undiagnosed Undertreated (Hashimoto’s thyroiditis, post surgery/ablation most common) Acute Precipitant Myxedemic Coma

28. Myxedemic Coma • Precipitants of Myxedemic Coma • Infection • Trauma • Vascular: CVA, MI, PE • Noncompliance with Rx • Any acute medical illness • Cold

29. KEY FEATURES of Myxedema

30. When should Myxedema be considered and what is the ddx? • Altered LOC • Structural vs metabolic causes of decreased LOC • Hypoventilatory Resp Failure • Narcotics, Benzodiazepines, EtOH intoxication, OSA, obesity hypoventilation, brain stem CVA, neuromuscular disorders (MG, GBS) • Hypothermia • Environmental • Medical: pituitary or hypothalamic lesion, sepsis

31. Myxedemic Coma • Investigations • TSH and Free T4 • Look for ppt • ECG • Labs • Septic work up (CXR/BC/urine/ +/- LP) • Random cortisol • CT head

32. Management of Myxedemic Coma • Levothyroxine is the cornerstone of Mx • Levothyroxine 500 ug po/iv (preferred over T3) • Ischemia and arrythmias possible: monitor • When in doubt, treat en spec • Other • Intubate/ventilate prn • Fluids/pressors/thyroxine for hypotension • Thyroxine for hypothermia • Stress Steroids: hydrocortisone 100 mg iv

33. Outline

34. Adrenal Insufficiency • Primary = Adrenal disease = Addison’s • Idiopathic, autoimmune, infectious, infiltrative, infarction, hemorrhage, cancer, CAH, postop • Secondary = Pituitary • Tertiary = Hypothalamus • Functional = Exogenous steroids

35. Etiology of Adrenal Crisis Underlying Adrenal Insufficiency (Addision’s and Chronic Steriods) Acute Precipitant Adrenal Crisis

36. Underlying Adrenal insufficiency Addison’s disease Chronic steroids No underlying Adrenal insufficiency Adrenal infarct or hemorrhage Pituitary infarct or hemorrhage Precipitants of Adrenal crisis Surgery Anesthesia Procedures Infection MI/CVA/PE Alcohol/drugs Hypothermia Acute adrenal crisis?

37. Adrenal Hemorrhage • Overwhelming sepsis (Waterhouse-Friderichsen syndrome) • Trauma or surgery • Coagulopathy • Adrenal tumors or infiltrative disorders • Spontaneous • Eclampsia, post-parturm, antiphospholipid Ab syndromes

38. Nonspecific Nausea, vomiting, abdominal pain Shock Distributive shock not responsive to fluids or pressors Laboratory (variable) Hyponatremia, hyperkalemia, metabolic acidosis Known Adrenal insufficiency Features of undiagnosed adrenal insufficiency Weakness, fatigue, weight loss, anorexia, N/V, abdo pain, salt craving, hyperpigmentation Key Features of Adrenal Crisis

39. Features of Adrenal Insufficiency

40. Hyperpigmentation

41. Hyperpigmentation

42. Adrenal Crisis • Consider on the differential diagnosis of SHOCK NYD

43. Adrenal Function Electrolytes Random cortisol ACTH Look for Precipitant ECG CXR Labs EtOH Urine Investigations

44. Management of Adrenal Crisis • Corticosteroid replacement • Dexamethasone 4mg iv q6hr is the drug of choice (doesn’t affect ACTH stim test) • Hydrocortisone 100 mg iv is an option • Mineralocorticoid not required in acute phase • Other • Correct lytes, fluid resuscitation (2-3L) • Glucose for hypoglycemia

45. Outline

46. Corticosteriod Stress Dosing:Who? When? How much? • Who needs stress steroids? • ?Addison’s • ?Chronic prednisone • ?Chronic Inhaled Steroids • When? • ? Laceration suturing • ? Colle’s fracture reduction • ? Cardioversion for Afib • ? Trauma or septic shock • How Much?

47. Effects of Exogenous Corticosteroids • Hypothalamic – Pituitary – Adrenal axis suppression • Has occurred with ANY route of administration (including oral, dermal, inhaled, intranasal) • Adrenal suppresion may last for up to a year after a course of steroids • HPA axis recovers quickly after prednisone 50 po od X 5/7

48. Streck 1979: Pituitary – Adrenal Recovery Following a Five Day Prednisone Treatment

49. Who needs Corticosteroid Stress Dosing? • Coursin JAMA 2002: Corticosteroid Supplementation for Adrenal Insufficiency • All patients with known adrenal insufficiency • All patients on chronic steroids equivalent to or greater than PREDNISONE 5 mg/day

50. Corticosteroid Stress Dosing: La Rochelle Am J Med 1993 • ACTH stimulation test to patients on chronic prednisone • Prednisone < 5 mg/day • No patient had suppressed HPA axis • Three had intermediate responses • Prednisone > or = 5 mg/day • 50% had suppressed HPA axis, 25% were intermediate, 25% had normal response