Non

1
Non Diabetic Endocrine Emergencies

• What an emerg doc needs to know
• Rob Hall PGY3
• December 5th, 2002

2
Non Diabetic Endocrine Emergencies

• WHY?

• Uncommon
• Potentially lethal
• Diagnostic dilemmas
• ED treatment may be life-saving

3
Outline
4
Objectives

• How uncommon?
• What defines thyroid storm, myxedemic coma,
  adrenal crisis?
• What are the main clinical features?
• When should these dx be considered?
• What investigations are pertinent?
• What is the emergency management?
• When and how do you give stress dosing for
  chronic adrenal insufficiency?

5
Case

• 37 yo female
• Chest Pain and SOB
• Denies any PMHx
• Recent weight loss

• Sinus tach 130
• Temp 40
• Agitated
• Tremulous

6
CASE
7
CASE

• NOT GOOD!

8
Thyroid Storm
9
What is Thyroid Storm?
10
What is Thyroid Storm?Burch 1993
11
Etiology of Thyroid Storm

• Undiagnosed
• Undertreated
• (Graves disease or Mulitnodular toxic
  goiter)

Acute Precipitant
Thyroid Storm
12
Thyroid Storm

• 1 of all hyperthyroids
• Mortality 30

• Precipitants
• Vascular
• Infectious
• Trauma
• Surgery
• Drugs
• Obstetrics
• Any acute medical illness

13
KEY FEATURES of Thyroid Storm

• FEVER
• TACHYCARDIA
• ALTERED LOC
• Features of underlying Hyperthyroidism
• Weight loss, heat intolerance, tremors, anxiety,
  diarrhea, palpitations, sweating, CP, SOB
• Goiter, eye findings, pretibial myxedema

14
When should you consider Thyroid Storm and what
is the ddx?

• Infectious sepsis, meningitis, encephalitis
• Vascular ICH, SAH
• Heat stroke
• Toxicologic
• Sympathomimetics, seritonin syndrome, neuroleptic
  malignant syndrome, Delirium Tremens,
  anticholinergic syndrome

15
INVESTIGATIONS

• Thyroid Testing
• TSH
• Free T4
• Dont need to order total T3/4, TBG, T3RU, FT3

• Look for precipitant
• ECG
• CXR
• Urine
• Labs
• Blood cultures
• Tox screen
• ? CT head
• ? CSF

16
Thyroid Storm Goals of Management

• 1 - Decrease Hormone Synthesis
• 2 - Decrease Hormone Release
• 3 - Decrease Adrenergic Symptoms
• 4 - Decrease Peripheral T4 -gt T3
• 5 - Supportive Care

17
Decrease Hormonal Synthesis

• Inhibition of thyroid peroxidase
• Propylthiouracil (PTU) or Methimazole (Tapazole)
• PTU is the drug of choice
• PTU 1000 mg po/ng/pr then 250 q4hr
• No iv form
• Safe in pregnancy
• S/E rash, SJS, BM suppression, hepatotoxic
• Contraindications previous hepatic failure or
  agranulocytosis from PTU

18
Decrease Hormone Release

• Iodine or lithium decreases release from hormone
  stored in colloid cells
• MUST not be given until 1hr after PTU
• Potassium Iodide (SSKI) 5 drops po/ng q6hr
• Lugols solution 8 drops q6hr

19
Decrease Adrenergic Effects

• Most important maneuver to decrease
  morbidity/mortality
• Decreases HR, arrythmias, temp, etc
• Propranolol 1 2 mg iv q 10 min prn
• Propranolol preferred over metoprolol
• Contraindications to beta-blockers
• Reserpine 2.5 5.0 mg im q4hr
• Guanethidine 20 mg po q6hr
• Diltiazem

20
Decrease T4 -gt T3

• Corticosteriods
• PTU and propranolol also have some effect
• Dexamethasone 2 4 mg iv
• Relative or absolute adrenal insufficiency also
  common

21
Supportive Care

• Fluid rehydration
• Correct electrolyte abnormalities
• Control temperature aggressively
• Ice, cooling blanket, tylenol, fans
• Search for precipitant
• Think vascular, infectious, trauma, drugs, etc

22
Summary of Management

• PTU
• PROPRANOLOL
• POTASSIUM IODIDE
• STERIODS
• SUPPORTIVE CARE

• P3S2

23
Apathetic Hyperthyroidism

• Elderly (can be any age)
• Altered LOC, Afib, CHF
• Minimal fever, tachycardia
• No preceeding hx of hyperthyroidism except weight
  loss
• More COMMON than thyroid storm
• Check TSH in any elderly patient with altered
  LOC, psych presentation, Afib, CHF

24
Outline
25
What is Myxedemic Coma?

• Myxedema swelling of hands, face, feet,
  periorbital tissues
• Myxedemic coma decreased LOC associated with
  severe hypothyroidism
• Myxedemic coma/Myxedema generally used to mean
  severe hypothyroidism

26
Myxedemic Coma

• Hypothyroidism

• Myxedemic Coma

27
Etiology of Myxedemic Coma

• Undiagnosed
• Undertreated
• (Hashimotos thyroiditis, post
  surgery/ablation most common)

Acute Precipitant
Myxedemic Coma
28
Myxedemic Coma

• Precipitants of Myxedemic Coma
• Infection
• Trauma
• Vascular CVA, MI, PE
• Noncompliance with Rx
• Any acute medical illness
• Cold

29
KEY FEATURES of Myxedema
30
When should Myxedema be considered and what is
the ddx?

• Altered LOC
• Structural vs metabolic causes of decreased LOC
• Hypoventilatory Resp Failure
• Narcotics, Benzodiazepines, EtOH intoxication,
  OSA, obesity hypoventilation, brain stem CVA,
  neuromuscular disorders (MG, GBS)
• Hypothermia
• Environmental
• Medical pituitary or hypothalamic lesion, sepsis

31
Myxedemic Coma

• Investigations
• TSH and Free T4
• Look for ppt
• ECG
• Labs
• Septic work up (CXR/BC/urine/ /- LP)
• Random cortisol
• CT head

32
Management of Myxedemic Coma

• Levothyroxine is the cornerstone of Mx
• Levothyroxine 500 ug po/iv (preferred over T3)
• Ischemia and arrythmias possible monitor
• When in doubt, treat en spec
• Other
• Intubate/ventilate prn
• Fluids/pressors/thyroxine for hypotension
• Thyroxine for hypothermia
• Stress Steroids hydrocortisone 100 mg iv

33
Outline
34
Adrenal Insufficiency

• Primary Adrenal disease Addisons
• Idiopathic, autoimmune, infectious, infiltrative,
  infarction, hemorrhage, cancer, CAH, postop
• Secondary Pituitary
• Tertiary Hypothalamus
• Functional Exogenous steroids

35
Etiology of Adrenal Crisis

• Underlying Adrenal Insufficiency
• (Addisions and Chronic Steriods)

Acute Precipitant
Adrenal Crisis
36
Acute adrenal crisis?

• Underlying Adrenal insufficiency
• Addisons disease
• Chronic steroids
• No underlying Adrenal insufficiency
• Adrenal infarct or hemorrhage
• Pituitary infarct or hemorrhage

• Precipitants of Adrenal crisis
• Surgery
• Anesthesia
• Procedures
• Infection
• MI/CVA/PE
• Alcohol/drugs
• Hypothermia

37
Adrenal Hemorrhage

• Overwhelming sepsis (Waterhouse-Friderichsen
  syndrome)
• Trauma or surgery
• Coagulopathy
• Adrenal tumors or infiltrative disorders
• Spontaneous
• Eclampsia, post-parturm, antiphospholipid Ab
  syndromes

38
Key Features of Adrenal Crisis

• Nonspecific
• Nausea, vomiting, abdominal pain
• Shock
• Distributive shock not responsive to fluids or
  pressors
• Laboratory (variable)
• Hyponatremia, hyperkalemia, metabolic acidosis

• Known Adrenal insufficiency
• Features of undiagnosed adrenal insufficiency
• Weakness, fatigue, weight loss, anorexia, N/V,
  abdo pain, salt craving, hyperpigmentation

39
Features of Adrenal Insufficiency
40
Hyperpigmentation
41
Hyperpigmentation
42
Adrenal Crisis

• Consider on the differential diagnosis of SHOCK
  NYD

43
Investigations

• Adrenal Function
• Electrolytes
• Random cortisol
• ACTH

• Look for Precipitant
• ECG
• CXR
• Labs
• EtOH
• Urine

44
Management of Adrenal Crisis

• Corticosteroid replacement
• Dexamethasone 4mg iv q6hr is the drug of choice
  (doesnt affect ACTH stim test)
• Hydrocortisone 100 mg iv is an option
• Mineralocorticoid not required in acute phase
• Other
• Correct lytes, fluid resuscitation (2-3L)
• Glucose for hypoglycemia

45
Outline
46
Corticosteriod Stress DosingWho? When? How much?

• Who needs stress steroids?
• ?Addisons
• ?Chronic prednisone
• ?Chronic Inhaled Steroids
• When?
• ? Laceration suturing
• ? Colles fracture reduction
• ? Cardioversion for Afib
• ? Trauma or septic shock
• How Much?

47
Effects of Exogenous Corticosteroids

• Hypothalamic Pituitary Adrenal axis
  suppression
• Has occurred with ANY route of administration
  (including oral, dermal, inhaled, intranasal)
• Adrenal suppresion may last for up to a year
  after a course of steroids
• HPA axis recovers quickly after prednisone 50 po
  od X 5/7

48
Streck 1979 Pituitary Adrenal Recovery
Following a Five Day Prednisone Treatment
49
Who needs Corticosteroid Stress Dosing?

• Coursin JAMA 2002 Corticosteroid Supplementation
  for Adrenal Insufficiency
• All patients with known adrenal insufficiency
• All patients on chronic steroids equivalent to or
  greater than PREDNISONE 5 mg/day

50
Corticosteroid Stress Dosing La Rochelle Am J
Med 1993

• ACTH stimulation test to patients on chronic
  prednisone
• Prednisone lt 5 mg/day
• No patient had suppressed HPA axis
• Three had intermediate responses
• Prednisone gt or 5 mg/day
• 50 had suppressed HPA axis, 25 were
  intermediate, 25 had normal response

51
Corticosteroid Stress Dosing

• What duration of prednisone is important?
• What about intermittent steroids?
• What about inhaled steroids?

52
Corticosteroid Stress Dosing Summary of
literature review

• Short courses of steroids are safe
• Many studies in literature documenting safety of
  prednisone X 5 10 days
• Wilmsmeyer 1990
• Documented safety of 14 day course of prednisone
• Sorkess 1999
• Documented HPA axis suppression in majority of
  patients receiving prednisone 10 mg/day X 4 weeks
• Many studies documenting HPA axis suppression
  with steroid use for gt one month

53
Corticosteroid Stress Dosing

• Inhaled Corticosteroids Allen 2002. Safety of
  Inhaled Corticosteroids.
• Adrenal suppression has occurred in moderate
  doses of ICS (Flovent 200 800 ug/day)
• Adrenal suppression is more common and should be
  considered with chronic high doses of ICS
  (Flovent gt 800 ug/day)

54
Corticosteroid Stress Dosing

• There is NO consistent evidence to reliably
  predict what dose and duration of corticosteroid
  treatment will lead to H-P-A axis suppression
• Why?

55
Corticosteroid Stress Dosing The bottom line

• Consider potential for adrenal suppression
• Chronic Prednisone 5 mg/day or equivalent
• Prednisone 20 mg/day for one month within the
  last year
• gt 3 courses of Prednisone 50 mg/day for 5 days
  within the last year
• Chronic high dose inhaled corticosteroids

56
When are stress steroids required?

• When is stress dosing required? (Cousin JAMA
  2002)
• Any local procedure with duration lt 1hr that
  doesnt involve general anesthesia or sedatives
  does NOT require stress dosing
• All illnesses and more significant procedures
  require stress dosing

57
Corticosteroid Stress Dosing
58
Corticosteroid Stress Dosing

• MINOR
• Double chronic steroid dose for duration of
  illness (only needs iv if cant tolerate po)
• MODERATE
• Hydrocortisone 50 mg po/iv q8hr
• MAJOR
• Hydrocortisone 100 mg iv q8hr

59
Corticosteroid Stress Dosing

• What about procedural sedation?
• ? Stress dose just before sedation/procedure
• Recommended by Coursin JAMA 2002 but NO
  supporting literature specific to procedural
  sedation in emerg
• Should be done --------gt Hydrocortisone 50 mg iv
  just before procedure and then continue with
  normal steroid dose

60
Outline
61
Non diabetic Hypoglycemia

• Fasting
• Insulinoma
• Insulin
• Sulfonylureas
• Liver dz
• H-P-A axis
• Fed
• Alimentary hyperinsulinism
• Congenital deficiency

• What labs to order BEFORE glucose
  administration????
• Serum glucose
• C-peptide level
• Insulin level
• Cortisol
• Sulfonylurea level

62
Non-diabetic Endocrine Emergencies

• Recognize key features
• Pattern of underlying dz precipitant
• Emergent management
• P3S2, levothyroxine, dex
• Supportive care and look for precipitant
• Consider corticosteroid stress dosing

63
The End