W. Heath Giles, M.D. University of Tennessee College of Medicine Chattanooga Assistant Professor of Surgery Associate Residency Program Director

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1 W. Heath Giles, M.D. University of Tennessee College of Medicine Chattanooga Assistant Professor of Surgery Associate Residency Program Director

2 It is our duty to each learner to honor your right to expect that your continuing medical education experience includes content and a learning environment that is free of commercial influence and conflicts of interest. To this end, UTCOMC requires program planners, speakers, and staff to disclose and resolve any relevant financial relationships with companies whose products may be discussed during the activity or who may support this program. For information on how any conflicts listed below were resolved, please contact the Surgery CME coordinator at W. Heath Giles, MD, reports having no financial relationships with commercial interests relevant to this presentation.

3 Understand the presentation, work-up, and treatment of endocrine emergencies encountered in the ICU Adrenal Insufficiency Thyroid Storm Hypercalcemia

4 Father of Endocrine Surgery Nobel Prize 1909 (Thyroid) Director of Surgery Clinic at Berne Instructed military doctors Produced most extensive research on gunshot wounds and the basis of the modern ideas of the mode of action of small caliber missiles with high initial velocity.

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7 Primary (Addison s disease) Adrenocortical disease Both cortisol and mineralocorticoid deficiency Secondary Pituitary (ACTH) Abrupt withdrawal glucocorticoids Cortisol deficiency only Tertiary Hypothalamus (CRH) Cortisol deficiency only

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9 Symptoms Weakness/fatigue Anorexia Nausea/vomiting Myalgia/arthralgia Headaches Depression Postural dizziness Physical Exam Hypotension Tachycardia Fever Increased pigmentation Laboratory findings Hyponatremia Hyperkalemia Hypoglycemia Hypercalcemia Eosinophilia

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11 Clues Hemodynamic instability despite adequate fluid resuscitation Hyperdynamic circulation Decreased SVR Ongoing evidence of inflammation without obvious source not responsive to empiric tx

12 Treatment Large bore IV access Serum electrolytes, glucose, cortisol, ACTH Bolus 2-3 liters NS or D5NS If no previous diagnosis adrenal insufficiency Dexamethasone 4mg IV If known diagnosis Hydrocortisone 100mg IV Correction electrolytes Supportive measures

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14 Rare but life-threatening Graves Disease, TMNG, Solitary toxic adenoma Can occur in patients with long-standing untreated hyperthyroidism but often precipitated by acute event Surgery Trauma Infection Acute iodine load Parturition

15 Pathophysiology unclear Rapid rate of increase in serum thyroid hormone Increased responsiveness to catecholamines Enhanced cellular responses to thyroid hormone Mortalilty: 20%

16 Presentation Tachycardia Fever ( ) CNS dysfunction Agitation, delirium, coma GI symptoms N/V, abd pain Elderly Toxic goiter New onset CHF/afib Tremor Goiter Exophthalmos Warm and moist skin

17 Diagnosis Thyrotoxicosis Elevated free T4/T3 Suppressed TSH Nonspecific Hyperglycemia Hypercalcemia Abnormal LFT Burch HB, Wartofsky L. Life-threatening thyrotoxicosis. Thyroid storm. Endocrinol Metab Clin North Am 1993; 22:263

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19 Treatment Supportive care IVF or diuretics for CHF Cooling blankets and Acetaminophen (NOT ASA) Treat precipitating condition Beta blocker control increased adrenergic tone Propranolol mg PO Q4-6hrs Esmolol *Calcium Channel blocker if unable to take BB x

20 Treatment Thionamide block new hormone synthesis PTU 200mg PO Q4hrs (also blocks peripheral T4 T3) Methimazole 20mg PO Q4-6hrs Iodine solution block release of hormone Lugol s solution 10 drops Q8hrs SSKI 5 drops Q6hrs *wait at least 1 hr after thionamide x x x x

21 Glucocorticoids reduce T4 T3 conversion Hydrocortisone 100mg IV Q6hrs Surgery If unable to take thionamide and need urgent correction of hyperthyroidism x

22 Causes Hyperparathyroidism Malignancy Thyrotoxicosis Milk alkali syndrome Hypervitaminosis D Lithium Thiazide diuretics Adrenal insufficiency Theophylline toxicity

23 Presentation GI Constipation Pancreatitis PUD Neuropsychiatric Anxiety Depression Lethargy Confusion Coma Renal dysfunction Kidney stones ARF Nephrogenic DI CV Shortened QT Arrhythmia HTN Cardiomyopathy Musculoskeletal Weakness Bone pain Fracture (osteoporosis)

24 Mild (Calcium < 12 mg/dl) No immediate treatment necessary Avoid aggravating factors Thiazides Volume depletion Inactivity High Ca diet

25 Moderate (Calcium mg/dl) If chronic and mildly symptomatic avoid aggravators If acute rise with change in sensorium treat as severe Severe (Calcium > 14 mg/dl) Volume expansion with isotonic saline ml/hr Loop diuretic only for renal failure and CHF Calcitonin 4 IU/kg Zoledronic acid 4mg IV over 15 min

26 Cooper and Stewart. Corticosteroid Insufficiency in Acutely Ill Patients. NEJM, Feb UpToDate Morita, Dackiw, and Zeiger. Endocrine Surgery Cameron. Current Surgical Therapy. 8 th Ed. Townsend et al. Sabiston Textbook of Surgery. 17 th Ed.

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