ENDOCRINE EMERGENCIES

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ENDOCRINE EMERGENCIES

• NANDALAL BAGCHI

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CASE 1

• 40 YEAR OLD WOMAN
• ONE DAY AFTER GALL BLADDER SURGERY
• NAUSEA , VOMITING
• EXTREME WEAKNESS
• HYPOTENSION, POOR RESPONSE TO FLUIDS AND PRESSORS
• SERUM K-5.5, Na-120

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CLINICAL CLUES PRIMARY

• HYPERPIGMENTATION
• HYPERKALEMIA
• VITILIGO

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CLINICAL CLUES SECONDARY

• PALE SKIN WITHOUT MARKED ANEMIA
• DEFICIENCY OF OTHER PITUITARY HORMONES
• PAST USE OF GLUCOCORTICOIDS
• HEADACHE
• VISUAL SYMPTOMS

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CAUSES PRIMARY,CHRONIC

• AUTOIMMUNE
• INFECTIONS TBC,FUNGAL, HIV
• METASTATIC CARCINOMA
• ADRENOMYELONEUROPATHY
• ISOLATED GC DEFICIENCY

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CAUSES SECONDARY,CHRONIC

• TUMORS
• SURGERY, IRRADIATION
• LYMPHOCYTIC HYPOPHYSITIS
• GRANULOMAS
• CHRONIC GC THERAPY
• CRH DEFICIENCY

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CAUSES ACUTE

• ADRENAL HEMORRHAGE/NECROSIS SEPSIS, BLEEDING
• POSTPARTUM NECROSIS OF THE PITUITARY
• PITUITARY APOPLEXY
• HEAD TRAUMA

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LABORATORY DIAGNOSIS

• BASELINE ACTH, CORTISOL
• COSYNTROPIN TEST
• MRI PITUITARY SELECTED CASES

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PRIMARY VS. SECONDARY

• PROLONGED ACTH STIMULATION
• RENIN, ALDOSTERONE
• INSULIN HYPOGLYCEMIA
• METYRAPONE
• CRH STIMULATION TEST

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TREATMENT

• HYDROCORTISONE IV 100MG FOLLOWED BY 100-200MG
  OVER NEXT 24H
• GLUCOSE SALINE 2-3L
• MONITOR ELECTROLYTES
• ORAL THERAPY IN 1-2 DAYS
• HYDROCORTISONE
• FLUDROCORTISONE

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CASE

• 30 YEAR OLD WOMAN
• ADMITTED WITH PNEUMONIA
• MILDLY DISORIENTED
• TEMP. 103, PULSE 150/MIN
• THYROID ENLARGED
• TREMOR, BRISK DTR, WARM MOIST SKIN

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THYROID STORM DIAGNOSIS

• EVIDENCE OF SEVERE HYPERTHYROIDISM
• END ORGAN FAILURE CNS,CVS
• MAJOR STRESSFULL EVENT
• TFT CONSISTENT WITH OVERT HYPERTHYROIDISM
• A CLINICAL DIAGNOSIS

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CAUSES

• GRAVES DISEASE
• RARELY
• TOXIC NODULAR GOITER
• EXCESSIVE THYROXINE INGESTION
• OTHER CAUSES

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TREATMENT

• BLOCK HORMONE SYNTHESIS
• PTU 150MG EVERY 6H
• BLOCK HORMONE RELEASE
• SSKI 5-10 DROPS EVERY 8H
• BLOCK BETA ADRENERGIC SYSTEM
• PREDNISONE 30-40 MG OVER 24H
• PLASMAPHERESIS, DIALYSIS
• FLUIDS, COOLING, NO ASA

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CASE

• 70 YEAR OLD WOMAN, LIVES ALONE
• POORLY RESPONSIVE
• VITALS T 92, P 50/M, R 10/M, BP 90/60
• COOL DRY SKIN,PUFFY EYES
• THYROID NOT PALPABLE, NO NECK SCAR
• DTR SLOW RETURN
• STOOL MELENA

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MYXEDEMA COMA DIAGNOSIS

• EVIDENCE OF SEVERE HYPOTHYROIDISM
• EVIDENCE OF END ORGAN FAILURE
• CNS,CVS,RENAL,RESPIRATORY
• PREDISPOSING CAUSES
• R/O OTHER CAUSES OF HYPOTHERMIA
• LABS CONSISTENT WITH SEVERE DISEASE

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DIAGNOSTIC PROBLEMS

• HYPOTHERMIA HAS MANY CAUSES
• COMA HAS MANY CAUSES
• INFECTION IS HARD TO RECOGNIZE

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PREDISPOSING FACTORS

• INFECTION
• DRUGS ANESTHETICS, OTHER CNS DEPRESSANTS
• HYPOTENSION e.g. GI BLEEDING.
• CARDIAC CAUSES MI,CHF
• PROLONGED COLD EXPOSURE

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TREATMENT

• SUPPORTIVE
• CAREFUL WARMING
• SUPPORT BP, RESPIRATION
• TREAT UNDERLYING DISEASE
• L-THYROXINE IV 250-500 mcg BOLUS, THEN 100
  mcgDAILY AFTER 48H OR,
• TRIIODOTHYRONINE 12.5 mcg EVERY 8H

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