Case Studies in Endocrinologic Emergencies High Risk Emergency Medicine 2017

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1 Case Studies in Endocrinologic Emergencies High Risk Emergency Medicine 2017 Corey M. Slovis, M.D. Vanderbilt University Medical Center Metro Nashville Fire Department Nashville nternational Airport Nashville, TN A malnourished cachectic alcoholic with AMS is picked up by EMS and has a glucose of 40 mg%. The ED physician gives the order for an amp of D50 and the patient arrives 20 minutes later. On arrival he receives 100 mg V thiamine. The upstairs doctors point out how naive the ED Doc is because glucose before thiamine can rapidly cause Wernicke s. Are they right? rish J Med Sci 1981;150: Can giving V glucose before Thiamine cause acute Wernicke s Encephalopathy? rish J Med Sci 1981;150: rish J Med Sci 1981;150:

2 rish J Med Sci 1981;150: rish J Med Sci 1981;150: Give 100 mg V push V is very safe Thiamine Give to all malnourished and cachetic patients Give after hypoglycemic emergencies; NOT before Wernicke s Encephalopathys Ataxia Ocular findings nystagmus or lateral rectus palsy Encephalopathy Classic Triad Signs in Wernicke-Korsakoff Complex J Neurol Nuerosurg Psych 1986;49: Excellent Review Ann Emerg Med 2007;50: Mental 34% Eye 2.1% Mental/Ataxia 17.5% More than just chronic alcoholics at risk Persistent neurologic dysfunction common Do not expect the triad Ataxia 1.0% Two Signs 27.8% Three Signs Classical Triad 16.5% No signs 18.6% One Sign 37.1% Eye/Mental 8.2% Eye/Ataxia 2.1% 2

3 What 5 groups are at higher risk for Wernicke s? 5 High Risk Groups for Wernickes s Chronic Ethanol Abuse Chronic Severe Malnutrition - (HV, Cancer, Prisoners, Refugees, etc.) Malabsorption Syndrome - (Short Gut Syndrome s/p gastric bypass, DM, etc.) Hyperemesis Gravidarum Anorexia Nervosa Hypoglycemia ReExPLAND Why does every hypoglycemic patient s low blood glucose have to be ReExplained? Re Ex P L A N D Renal Exogenous nsulin/antihyperglycemics Pituitary nsufficiency Liver Alcohol, Addison s, Aspirin nfection, nsulinoma Neoplasm Drugs Hypoglycemia ReExPLAND Hypoglycemia (Renal) Re Ex P L A N D Renal Exogenous nsulin/antihyperglycemics Pituitary nsufficiency Liver Alcohol, Addison s, Aspirin nfection, nsulinoma Neoplasm Drugs Decreased insulinase Decreased excretion Decreased caloric intake ncreased number of infection 3

4 Hypoglycemia (nfection) Hypoglycemia in the very young or very old equals infection/sepsis until proven otherwise One amp of D 50 should raise serum glucose by about 200 mg/dl for up to 30 minutes. f it doesn t look for complicating factors like sepsis, insulin OD, oral agent OD, or ASA OD D 50 % vs D 10 % Prehosp Emerg Care 2017;21:79-82 D 10 vs D 50 D 50 osmolarity = 2,525 mosm ph = Hypertonic and acidotic = phlebitis D 10 = 505 mosm Authors suggest using D 10 D 10 vs D 50 Take Homes Prehosp Emerg Care 2017;21:63-7 Can D 10 W be substituted for D 50 W? 24 month trial of 871 pts, 100 ml D 10 W Contra Costa EMS and Highland Hospital Average initial glucose was 37; repeat 91 mg % 23% required a second bolus 0.8% (< 1:100) required a third Both raise glucose effectively D 50 to 250 in 5 min; D 10 to 100 in 10 min May need to repeat D 10 in 1:4 patients D 10 may be safer No definitive head to head large trial yet 4

5 The 5 Most Common Endocrine Complaints Refractory Weakness Arrhythmias Altered Mental Status Fluid and Electrolyte Abnormalities What one word will help you the most to think Endocrine cause? Refractory = Endocrine Refractory = Endocrine Hypotension Hypothermia Bradycardia Tachycardia Arrhythmia Refractory Shock NOT due to Sepsis AM PE Drugs Hypothermia A hypothermic patient presents to the ED. How many therapies should you always consider? Endocrine - Metabolic 5

6 5 Heated O 2 N,G,T Synthroid Steroids Hypothermia Therapies to Consider Begin Therapy for Hypothermia Narcotic OD, Hypoglycemia, Wernicke s Hypothyroid Hypoadrenal/Hypothyroid The most common cause of Hyperthyroidism in the ED is: Graves Disease Antibiotics Sepsis 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 What 2 arrhythmias should always make you think of Hyperthyroidism? Atrial Fibrillation with Rapid Ventricular Response Refractory PSVT and/or PSVT that breaks but rapidly reoccurs S/P adenosine and/or cardioversion Activation of Graves Disease is usually due to: Discontinuing Medication Triggering Stress When you see a Hyper or Hypo Thyroid Crisis, think: Precipitating Cause! 6

7 When you see a Hyper or Hypo Thyroid Crisis, also think: Adrenal nfection Hyperthyroidism R/O Triggering Stress Pregnancy Trauma Recent surgical procedures High emotional stress J Emerg Med 1996;14: Treatment of Hyperthyroidism ABC s NGT Block peripheral action Block synthesis Avoid relative hypoadrenalism Treatment of Hyperthyroidism Block peripheral action - Beta Blockade Block synthesis - PTU or Methimazole Avoid relative hypoadrenalism - Steroids 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! 7

8 O 2 The Opening Gambit Treatment of Hyperthyroidism ABC, NGT O 2 Sat V Access ECG Monitor Begin D 5 NSS at 200 cc/hr 12 Lead ECG Beta Blockers in Hyperthyroidism 2 T 3 T 4 T 4 T 3 Brain Heart Body As much as it takes but not too much nderal 1mg Q5 minutes ntake of odine Synthesis of Thyroid Hormone (Organification) Release of Active T 4, T 3 Conversion of T 4 to T 3 Stimulus effects on the body Esmolol 1/2 pts Wt in Kgs V push then 1/10 of loading dose/min e.g.: 60 kg woman = 60/2 = 30 mg V push = 3 mg/min Beta Blockers 2 T 3 T 4 T 4 T 3 Brain Heart Body Beta Blockers block peripheral actions of Thyroid Hormone And also decrease peripheral conversion of T 4 T 3 PTU or Methimazole Blocks T 3 and T 4 Formation Work Rapidly Must be given orally PTU decreases T 4 T 3 conversion Dose is: - PTU 200 mg Q4H - Methimazole 20 mg Q4H 8

9 PTU or Methimazole 2 T 3 T 4 T 4 T 3 Blocks the formation of Active Thyroid Hormone PTU decreases T 4 T 3 conversion Brain Heart Body Steroids in Hyperthyroidism Preserve Homeostasis Avoid Hypo Adrenal Crisis Decrease T 4 T 3 Conversion Steroids 2 T 3 T 4 T 4 T 3 Steroids help decrease T 4 T 3 conversion Steroids help borderline hypoadrenalism Steroids supports organ function Brain Heart Body Steroids Use in Thyroid Disease Use in Adrenal Disease Hydrocortisone 100 mg Decadron 6 mg Solumedrol mgs Treatment of Hyperthyroidism 2 T 3 PTU Methimazole T 4 T 4 T 3 PTU Beta Blockers Steroids Organification Conversion Effects Brain Heart Body Beta Steroids Blockers Support Thyroid Storm Thyrotoxic Crisis Agitation/AMS High fever Tachycardia > 140 AFib with RVR Cardiovascular collapse 9

10 Treatment of Thyroid Storm ABC/NGT (O 2, D 5 NSS) Titrate Beta Blocker Begin PTU or Methimazole Bolus with Steroids odine (1) 2 T 3 T 4 T 4 T 3 Brain Heart Body odine administration stimulates T 3 and T 4 formation Administer odine Treatment of Hyperthyroidism-odine Large doses of iodine blocks release of active Thyroid Hormone and new Formation if PTU or Methimazole already onboard Wait 1 hour s/p PTU or Methimazole before odine administration odine (2) odine Therapy in Thyroid Storm 2 T 3 T 4 T 4 T 3 Brain Heart Body SSK (0.25 ml / 5 drops) Lugol s Solution (0.5 ml / 10 drops)* odine in Large Doses Blocks Release of Active T 4 and T 3 But: also stimulates new T 3 and T 4 formation f you give odine, block T 3 /T 4 formation by first giving PTU odinated Contrast (1 gram inorganic ) * Can also be given V 10

11 Treatment of Thyroid Storm 2 T 3 PTU Methimazole T 4 T 4 T 3 odine PTU Beta Blockers Steroids Beta Blockers Brain Heart Body Steroids Hypothyroidism Organification Release Conversion Effects Support Think Hypothyroidism What patient types should make us consider Hypothyroidism? Elderly with dementia CHF patient on diuretics with hyponatremia Hypertensive with repeat episodes of hypotension Fecal impaction, abdominal cramps, constipation Digitalis toxicity - even with decreasing dosage Most acute and some chronic ED presentations of hypothyroidism have a: precipitating cause: Myxedema A hypothyroid patient with AMS + Significant Vital Sign Abnormalities Find it! 11

12 Classic Myxedema Patients: When should you consider myxedema? AM with shock, poor response to pressors Symptomatic bradycardia, poor response to atropine and/or TQ pace Hypothermia in the spring, summer or fall Hypothermia that won t warm up AMS with sepsis BP: P: RR: Temp: O 2 sat: Myxedema 5 Vital Signs Hypotensive Bradycardic Hypercarbia Hypothermic Hypoxic Hypothyroid Patients Hypoventilate! Treatment of Hypothyroidism: 100 ugm (0.1 mg) of synthroid (T 4 ) daily. Secure ABC s: Treatment of Myxedema High F i O 2 : Consider intubation Consider NGT: Beware hypoglycemia Thyroid Replacement: 400 ugm of Synthroid or 100 ugm T 3 Steroids: 100 mg V of hydrocortisone, or decadron R/O underlying disease: R/O AM, sepsis, head trauma, UT etc. 12

13 Hypothyroidism = Hyponatremia Hypothyroid = Hypoadrenal Adrenal Hormones Salt Water Energy Drink Aldosterone: Salt and Water Retention Cortisol: Energy Pressor Response Consider Adrenal nsufficiency Asthmatics (or history of steroid use) HV-ADS (infiltrative disease with MA) Myxedema (or any endocrine disease) Meningiococcemia and Fulminant Sepsis Any Refractory Shock Patient - BP hypotensive - P bradycardic - Temp hypothermic Consider Adrenal nsufficiency n any Hyperkalemic patient without renal failure n any Hypotensive patient not responding to volume or pressors n any Hypothermic patient not rewarming Treatment of Hypoadremalism Volume Glucose Sodium Steroids Diagnosis 13

14 Therapy of Adrenal nsufficiency Secure ABCs O 2, Volume, Na (D 5 NSS, cc/hr) NGT Glucose (D 5 NSS, cc/hr) Draw Red Top Label time drawn V Therapy in Hypoadrenalism Patients need sodium Volume at cc/hr Bolus for shock Patients need glucose Use D 5 NSS Not just NSS Therapy of Adrenal nsufficiency Steroids 6 mg Decadron ugm Corticotropin Find Cause R/O infection, infarction Redraw red top in min Diagnosing Addison s Disease Cosyntropin Stimulation Test Draw red top tube* Give 6 mg Decadron And 250 ugm Corticotropin Draw second red top min later* See if Cortisol level 20 (or doubles) * Label Times!! Diagnosis of Hypoadrenalism Failure of cortisol level to rise to 20 ugm/dl, or at least double. Name that Endocrinopathy 1 Hypothyroid 2 Hyperthyroid 3 Hypoadrenalism 4 Wernicke s 5 Hypoglycemia 14

15 A. A 48 year old male asthmatic suffers an inferior AM 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 D 50. 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. Hyponatremic seizure. Hypothyroid F. Sodium of 128. Hypothyroid, Hypoadrenal G. Sick sinus syndrome. Hypothyroid H. Weight loss. Hyperthyroid. Anorexia in healthy person. Hyperthyroid J. Meningitis and WNL CSF. Thyroid Storm K. ADS. Hypoadrenal.. Wernicke s Too? L. Unresponsive Wernicke s (coma, hypothermia, hypotension, bradycardia) Hypoadrenal M. pco 2 of 45. Hypothyroid N. Hyponatremia, hyperkalemia. Hypoadrenal Summary 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 Watch for Wernicke vulnerable Re-explained hypoglycemia Refractory = R/O endocrine Glu, BB, PTU, Steroids () Think Thyroid, Think Adrenal 15

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