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Endocrine Emergencies

Corey M. Slovis, M.D.Vanderbilt University Medical Center

Metro Nashville Fire DepartmentNashville International Airport

Nashville, TN

Hyperthyroidism

TSHTell us what the Pituitary is Seeing

Almost undetectable = Hyperthyroid

No stimulation needed

Very High = Hypothyroid

Pituitary wild to get thyroid stimulated

Everything is Hyper in Hyperthyroidism except menses

Amenorrhea is due to undetectable TSH levels which blocks LH Surge

What are some common ED complaints that should make us think: R/O Hyperthyroidism?

Think Thyroid Disease “ED Crocks”

• Anxious and multiple nonspecific complaints

• Young, healthy but “weak”

• Amenorrhea but negative pregnancy test

• Diarrhea but otherwise healthy

• Palpations in exercising “over-achiever”

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The one arrhythmia to always make you think of Hyperthyroidism is

Atrial Fibrillation with Rapid Ventricular Response

The most common cause of Hyperthyroidism in the ED is:

Graves Disease

Activation of Graves Disease is usually due to:

• Discontinuing Medication

• Triggering Stress

When you see a Hyper orHypo Thyroid Crisis, think:

Precipitating Cause!

When you see a Hyper orHypo Thyroid Crisis, think:

Adrenal

HyperthyroidismR/O Triggering Stress

• Infection

• Pregnancy

• Trauma

• Recent surgical procedures

• High emotional stress

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J Emerg Med 1996;14:697-701 Am J Emerg Med 2001;19:603-604

Treatment of Hyperthyroidism

• ABC’s

• NGT

• Block peripheral action

• Block synthesis

• Avoid relative hypoadrenalism

Treatment of Hyperthyroidism ABC, NGT

• Perform Opening Gambit

• Patients volume contracted

• High metabolism = Low Glucose Reserves

• Tachyarrhythmias common

• Treat the disease….Not just the rhythm!

The Opening Gambit

• O2

• O2 Sat

• IV Access

• ECG Monitor

• 12 Lead ECG

I

I

Intake of Iodine

I T3

T4

I2

Synthesis of Thyroid Hormone (Organification)

Release of Active T4 , T3

T4 T3

Conversion of T4 to T3

Brain

Heart

Body

Stimulus effects on the body

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Treatment of Hyperthyroidism ABC, NGT

Begin D5NSS at 200 cc/hr

Beta Blockers in Hyperthyroidism

• As much as it takes but not too much

• Inderal 1mg Q5 minutes

• Esmolol 1/2 pts Wt in Kgs IV push

e.g.: 60 kg woman = 60/2 = 30 mg IV push = 3 mg/min

then 1/10 of loading dose/min

I

II

T3

T4

T4 T3

Brain

Heart

Body

I2

Beta Blockers

And also decrease peripheral conversion of T4 T3

Beta Blockers block peripheral actions of Thyroid Hormone

PTU in Hyperthyroidism

• Blocks T3 and T4 Formation

• Works Rapidly

• Must be given orally

• Also decreases T4 T3 conversion

• Dose is 250 mg TID

But load with 750 mg po acutely

I

II

T3

T4

T4 T3

Brain

Heart

Body

I2

PTU

PTU blocks the formation of Active Thyroid Hormone

And decreases T4 T3 conversion

Steroids in Hyperthyroidism

• Preserve Homeostasis

• Avoid Hypo Adrenal Crisis

• Decrease T4 T3 Conversion

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I

II

T3

T4

T4 T3I2

Steroids

Steroids help decrease T4 T3 conversion

Steroids help borderline hypoadrenalism

Brain

Heart

Body

Brain

Heart

Body

Steroids supports organ function

Steroids

• Use in Thyroid Disease

• Use in Adrenal Disease

• Hydrocortisone 100 mg

• Decadron 6 mg

• Solumedrol 80 – 120 mgs

Steroid Equivalent Doses 20, 5, 4, .75

• 20 mg of Hydrocortisone

• 5 mg of Prednisone

• 4 mg of Solumedrol

• 0.75 mg of Decadron

I

II

T3

T4

T4 T3

Brain

Heart

Body

I2

Support

Brain

Heart

Body

PTU SteroidsPTUBetaBlockers

Steroids

Beta Blockers

Organification Conversion Effects

Treatment of Hyperthyroidism

Treatment of Thyroid Storm

• ABC/NGT

• Titrate Inderal 1 mg Q 3-5 min

• Begin PTU 750 mg PO

• Bolus with Steroids

• Administer Iodine

I

II

T3

T4

T4 T3

Brain

Heart

Body

I2

Iodine (1)

Iodine administration stimulates T4 formation

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Treatment of Hyperthyroidism-Iodine

if PTU already onboard

Large doses of iodine blocks release ofactive Thyroid Hormone and

new Formation

I

II

T3

T4

T4 T3

Brain

Heart

Body

I2

Iodine (2)

If you give Iodine, block T3/T4 formation by first giving PTU

But: also stimulates new T3 and T4 formation

Iodine in Large Doses Blocks Release of Active T4 and T3

Where in the hospital

is Iodine?

Treatment of Thyroid Storm

• IV D5NSS 200 cc/hr

• Titrate Inderal 1 mg Q5

• PTU 750 mg PO

• Bolus Steroids (100mg Hydrocortisone)

• Iodine for Storm (1 gram Hypaque)

I

II

T3

T4

T4 T3

Brain

Heart

Body

I2

Brain

Heart

Body

PTU Iodine SteroidsPTUBetaBlockers

Steroids

Beta Blockers

Organification Release Conversion Effects Support

Treatment of Thyroid Storm

Hypothyroidism

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What patient types should make us consider

Hypothyroidism?

Hypothyroidism“Chronic complainers”

• Elderly with dementia

• CHF patient on diuretics with hyponatremia

• Digitalis toxicity – even with decreasing dosage

• Hypertensive with repeat episodes of hypotension

• Fecal impaction, abdominal cramps, constipation

• “Would minoxydil help?” – hair loss

Most acute and some chronic ED presentations of

hypothyroidism have a:

precipitating cause:

Find it!

Myxedema

• A hyperthyroid patient with:

AMS

Significant Vital Sign Abnormalities

+

When should you consider myxedema coma?

Classic Myxedema Coma Patients:

• AMI with shock, poor response to pressors

• New Sick Sinus Syndrome, poor response to atropine

• Hypothermia in the spring, summer or fall

• Hypothermia that won’t warm up

• AMS with sepsis

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Myxedema Coma5 Vital Signs

• BP: Hypotensive• P: Bradycardic• RR: Hypercarbia

• Temp: Hypotensive

• O2 sat: Hypoxic

Hypothyroid Patients Hypoventilate!

A hypothermic patient presents to the ED.

How many therapies should you always consider?

Hypothermia Therapies to Consider

• Heated O2

• N,G,T

• Synthroid

• Steroids

• Antibiotics

Begin Therapy for Hypothermia

Narcotic OD, Hypoglycemia,

Hypothyroid

Hypoadrenal/Hypothyroid

Sepsis

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Wernicke’s

100 ugm (0.1 mg) of synthroid (T4) daily.

Treatment of Hypothyroidism: Treatment of Myxedema Coma

Secure ABC’s: High FiO2: Consider intubation

Consider NGT: Beware hypoglycemia

Thyroid Replacement: 400 ugm of Synthroid or 100 ugm T3

Steroids: 100 mg IV of hydrocortisone, or decadron

R/O underlying disease: R/O AMI, sepsis, head trauma, UTI etc.

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Hypothyroidism = Hyponatremia Hypothyroid = Hypoadrenal

A hypothyroid asthmatic

• How many clues to this endocrine disease?

• What medication is key to curing him?

with AIDSpresents with purpuric lesionson his chest.

Meds include coumadin.

HypoAdrenalism

Adrenal Hormones

• Aldosterone: Salt and Water Retention

• Cortisol: Energy – Pressor Response

“Salt Water Energy Drink”

Consider Adrenal Insufficiency• Asthmatics (or history of steroid use)

• AIDS (infiltrative disease with MAI)

• Myxedema (or any endocrine disease)

• Meningiococcemia and Fulminant Sepsis

• Any “Refractory Shock Patient”- BP hypotensive- P bradycardic- Temp hypothermic

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Consider Adrenal Insufficiency

• In any Hyperkalemic patient without renal failure

• In any Hypotensive patient not responding to volume or pressors

• In any Hypothermic patient not rewarming

Treatment of Hypoadremalism

• Volume

• Glucose

• Sodium

• Steroids

• Diagnosis

Therapy of Adrenal Insufficiency

• Secure ABCs– O2, Volume, Na (D5NSS, 250-1000 cc/hr)

• NGT– Glucose (D5NSS, 250-1000 cc/hr)

• Draw Red Top– Label time drawn

IV Therapy in Hypoadrenalism

• Patients need sodium – Volume at 250 - 1000 cc/hr

– Bolus for shock

• Patients need glucose– Use D5NSS

– Not just NSS

Therapy of Adrenal Insufficiency

• Steroids – 6 mg Decadron

+– 250 ugm Corticotropin

• Find Cause– R/O infection, infarction– Redraw red top in 30-60 min

Diagnosing Addison’s DiseaseCosyntropin Stimulation Test

• Draw red top tube*

• Give 6 mg Decadron

• And 250 ugm Corticotropin

• Draw second red top 30 – 60 min later*

• See if Cortisol level 20 (or doubles)

* Label Times!!

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Steroid Equivalent Doses 20, 5, 4, .75

• 20 mg of Hydrocortisone

• 5 mg of Prednisone

• 4 mg of Solumedrol

• 0.75 mg of Decadron

Failure of cortisol level to rise to 20 ugm/dl, or at least double.

Diagnosis of Hypoadrenalism

A 54 year old female s/p gastrectomy presents with AMS and hypoglycemia. She is rehydrated and improves significantly.

• Why does she develop ataxia and ophthalmoplegia?

• Can thiamine be given in IV?

• Should it precede glucose?

• What is the classic triad vs the unusual pentad?

A medical student faints while

urinating. His BP is 300/200

and he is sweating, but 5

minutes later is 120/70.

Pheo = Epinephrine SurgesWhat three symptoms

should make you think of pheochromocytoma?

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The Classic Triad of Pheos

Episodic Headache

with

and

Palpitations

Sweating

Headache, Palpitations, Sweating

Think Pheo

Suspect Pheochromocytoma

• Chronic Hypertension

• Paroxsyml Hypertension

• Headache

• Palpitations

• Sweating

+/or

plus

Paroxysmal Hypertension

Think Pheo

Major Symptoms of Pheochromocytomas

• Hypertension

• Sweating

• Tachycardia

• Headache

• Apprehension

Pheochromocytoma Symptoms

• Almost always paroxysmal

• Often last only a few minutes

• Rarely more than 1 hour

• Reoccurs in days, weeks, or months

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Hypertension in Pheo’s 50:50

Hypertension is the number 1 symptom BUT…

50% have chronic Hypertension + Paroxysmal

50% have WNL Blood Pressure + Paroxysmal

• Nipride

and/or

• Consider Phentolamine

Hypertenvise Crisis in Pheo

1 Hypothyroid

2 Hyperthyroid

3 Hypoadrenalism

4 Wernicke’s

5 Pheochromocytoma

Name that Endocrinopathy A. A 48 year old male asthmatic suffers an inferior AMI and does not respond to pressors. Hypoadrenal

B. A 68 year old elderly female presents in coma due to hypoglycemia. She does not wake up after 2 amps of D50. Hypoadrenal…. Hypothyroid too?

C. A hypothermic alcoholic does not rewarm.Wernicke’s…. Hypoadrenal too?

D. A 28 year old woman presents in PSVT which keeps relapsing after therapy with adenosine, verapamil and 200 ws DC cardioversion.

Hyperthyroid

E. Hypertensive bleed. Pheo

F. Hyponatremic seizure. Hypothyroid

G. Sodium of 128. Hypothyroid, Hypoadrenal

H. Sick sinus syndrome. Hypothyroid

I. Weight loss. Hyperthyroid

J. Anorexia in healthy person. Hyperthyroid

K. Meningitis and WNL CSF. Thyroid Storm

L. AIDS. Hypoadrenal.. Wernicke’s Too?

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M. Unresponsive Wernicke’s (coma, hypothermia, hypotension, bradycardia)

Hypoadrenal

N. pCO2 of 45. Hypothyroid

O. Acute psychotic runner. Hyperthyroid Pseudo Pheo???

P. Hyponatremia, hyperkalemia. Hypoadrenal

Q. Fecal impaction in NH patient. Hypothyroid

R. Coma with pinpoint pupils, bradycardia and hypotension. Wernicke’s

S. Persistent hypotension s/p major trauma no bleeding site found. Hypoadrenal

Summary

Be Gentle in NKHC

Refractory = Endocrine

Think Precipitating Causes

“Sepsis” = R/o Endocrine

Give Thiamine More