Endocrine emergencies triner 2013

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


Dominant Symptoms


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 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 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 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



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 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


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

Endocrine emergencies triner 2013

Health & Medicine

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