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

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1 Endocrine Emergencies Corey M. Slovis, M.D. Vanderbilt University Medical Center Metro Nashville Fire Department Nashville nternational Airport Nashville, TN Hyperthyroidism TSH Tell 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 1

2 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 or Hypo Thyroid Crisis, think: Precipitating Cause! When you see a Hyper or Hypo Thyroid Crisis, think: Adrenal nfection Hyperthyroidism R/O Triggering Stress Pregnancy Trauma Recent surgical procedures High emotional stress 2

3 J Emerg Med 1996;14: Am J Emerg Med 2001;19: 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 O 2 O 2 Sat V Access ECG Monitor ntake of odine 2 Synthesis of Thyroid Hormone (Organification) Release of Active, Conversion of to Stimulus effects on the body 12 Lead ECG 3

4 Treatment of Hyperthyroidism ABC, NGT Begin D 5 NSS at 200 cc/hr Beta Blockers in Hyperthyroidism As much as it takes but not too much nderal 1mg Q5 minutes 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 PTU in Hyperthyroidism 2 Blocks and Formation Works Rapidly Must be given orally Beta Blockers block peripheral actions of Thyroid Hormone And also decrease peripheral conversion of Also decreases conversion Dose is 250 mg TD But load with 750 mg po acutely PTU 2 PTU blocks the formation of Active Thyroid Hormone And decreases conversion Steroids in Hyperthyroidism Preserve Homeostasis Avoid Hypo Adrenal Crisis Decrease Conversion 4

5 Steroids 2 Steroids help decrease conversion Steroids help borderline hypoadrenalism Steroids supports organ function Steroids Use in Thyroid Disease Use in Adrenal Disease Hydrocortisone 100 mg Decadron 6 mg Solumedrol mgs Steroid Equivalent Doses 20, 5, 4, mg of Hydrocortisone 5 mg of Prednisone 4 mg of Solumedrol Treatment of Hyperthyroidism PTU 2 Organification PTU Beta Blockers Steroids Beta Steroids Blockers Conversion Effects Support 0.75 mg of Decadron Treatment of Thyroid Storm ABC/NGT Titrate nderal 1 mg Q 3-5 min Begin PTU 750 mg PO Bolus with Steroids odine (1) 2 odine administration stimulates formation Administer odine 5

6 Treatment of Hyperthyroidism-odine Large doses of iodine blocks release of active Thyroid Hormone and new Formation odine (2) 2 if PTU already onboard odine in Large Doses Blocks Release of Active and But: also stimulates new and formation f you give odine, block / formation by first giving PTU Treatment of Thyroid Storm Where in the hospital is odine? V D 5 NSS 200 cc/hr Titrate nderal 1 mg Q5 PTU 750 mg PO Bolus Steroids (100mg Hydrocortisone) odine for Storm (1 gram Hypaque) Treatment of Thyroid Storm 2 PTU odine PTU Beta Blockers Steroids Beta Blockers Steroids Organification Release Conversion Effects Support Hypothyroidism 6

7 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 Classic Myxedema Coma Patients: When should you consider myxedema coma? AM 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 7

8 Myxedema Coma 5 Vital Signs BP: P: RR: Temp: O 2 sat: Hypotensive Bradycardic Hypercarbia Hypotensive Hypoxic Hypothyroid Patients Hypoventilate! A hypothermic patient presents to the ED. How many therapies should you always consider? 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 Antibiotics Sepsis Treatment of Hypothyroidism: 100 ugm (0.1 mg) of synthroid ( ) daily. Treatment of Myxedema Coma Secure ABC s: High F i O 2 : Consider intubation Consider NGT: Beware hypoglycemia Thyroid Replacement: 400 ugm of Synthroid or 100 ugm Steroids: 100 mg V of hydrocortisone, or decadron R/O underlying disease: R/O AM, sepsis, head trauma, UT etc. 8

9 Hypothyroidism = Hyponatremia Hypothyroid = Hypoadrenal A hypothyroid asthmaticwith ADS presents with purpuric lesionson his chest. Meds include coumadin. How many clues to this endocrine disease? What medication is key to curing him? HypoAdrenalism Adrenal Hormones Salt Water Energy Drink Aldosterone: Salt and Water Retention Cortisol: Energy Pressor Response Consider Adrenal nsufficiency Asthmatics (or history of steroid use) ADS (infiltrative disease with MA) Myxedema (or any endocrine disease) Meningiococcemia and Fulminant Sepsis Any Refractory Shock Patient - BP hypotensive - P bradycardic - Temp hypothermic 9

10 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 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!! 10

11 Steroid Equivalent Doses 20, 5, 4, mg of Hydrocortisone 5 mg of Prednisone Diagnosis of Hypoadrenalism Failure of cortisol level to rise to 20 ugm/dl, or at least double. 4 mg of Solumedrol 0.75 mg of Decadron 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 V? 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 Surges What three symptoms should make you think of pheochromocytoma? 11

12 The Classic Triad of Pheos Episodic with and Headache Palpitations Sweating Headache, Palpitations, Sweating Think Pheo Suspect Pheochromocytoma Chronic Hypertension +/or Paroxsyml Hypertension plus Headache Palpitations Sweating 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 12

13 Hypertension in Pheo s 50:50 Hypertenvise Crisis in Pheo Hypertension is the number 1 symptom BUT 50% have chronic Hypertension + Paroxysmal Nipride and/or Consider Phentolamine 50% have WNL Blood Pressure + Paroxysmal Name that Endocrinopathy 1 Hypothyroid 2 Hyperthyroid 3 Hypoadrenalism 4 Wernicke s 5 Pheochromocytoma 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. Hypertensive bleed. Pheo F. Hyponatremic seizure. Hypothyroid G. Sodium of 128. Hypothyroid, Hypoadrenal H. Sick sinus syndrome. Hypothyroid. Weight loss. Hyperthyroid J. Anorexia in healthy person. Hyperthyroid K. Meningitis and WNL CSF. Thyroid Storm L. ADS. Hypoadrenal.. Wernicke s Too? 13

14 M. Unresponsive Wernicke s (coma, hypothermia, hypotension, bradycardia) Hypoadrenal N. pco 2 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 14