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Flashcards in endocrine Deck (26)
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conditions that precede a thryoid storm

hyperthryoidism or thryoidtoxicosis


MCC of throid storm

Graves disease

autoimmune hyperthryoidism


MCC of hyperthryoidism




Autoimmune (Hashimoto’s disease) most common cause

Other causes include nonautoimmune thyroid failure, postablative/postsurgical, radiation tx, medications, toxins


presentation of hypothy

i. Fatigue
ii. Weakness
iii. cold intolerance
iv. constipation
v. weight gain,
vi. depression,
vii. impaired mental funx
viii. dry skin,
ix. coarse hair
x. hair loss,
xi. brittle nails,
xii. muscle weakness,
xiii. edema,
xiv. hoarseness
xv. dysphagia,
xvi. menstrual irregularity


e. Physical Exam hypothyroidism

i. Bradycardia
ii. Palpable goiter
iii. Macroglossia
iv. Delayed tendon reflexes


myexdema precipitation

a. Infection
b. MI
c. CVA
d. Trauma
e. Opioid use


1. Decreased mental status
2. Hypothermia
3. Bradycardia
4. Hypotension
5. Hypoventilation
6. Facial & periorbital edema, swollen lips, macroglossia, ptosis
7. Skin is cold and very dry, nonpitting edema can be found throughout
8. Precipitating illness

signs of

myexdema coma


dx of myexdema coma

1. Serum TSH, Free T4, (Free T3)
a. TSH can be as high as 600 (nml range 0.4-4.5)
b. T4/T3 levels may be undetectable

3. CMP (hypoglycemia, hyponatremia common)
4. CBC w/differential
5. EKG
6. CXR

check for adrenal insufficiency too


Checking for adrenal insufficiency before thyroid tx because...

Checking for adrenal insufficiency before thyroid tx b/c giving TH to low cortisol levels ---> hypermetabolic state


management of a myxedema coma includes

hyroid hormone (T4 alone vs T4 & T3):
a. Thyroxine 200-400mcg IV, followed by 50-100mcg qd;
b. Can add T3 5-20mcg IV, followed by 2.5-10mcg q8 hrs

supportive: a. electrolyte abnormalities
b. hypothermia
c. hypotension
d. ventilatory support

hydrocortisone if can't exclude adrenal insufficiency



Complications of hyperthyroid

Afib--> from too much thyroid

CHF leads to


3 treatments for a thyroid storm

1. Beta-blocker to control symptoms:
a. Propanolol 0.5-1mg IV over 10 minutes, then 1-2mg over 10 minutes every few hrs

2. Thionamides to block thyroid hormone synthesis:
a. Propylthiouracil (PTU) 200mg q4 hrs (po, NG tube, rectal)
b. Methimazole 20mg q4-6 hrs (po, NG tube, rectal)

3. Iodine to block release of T4/T3:
a. Lugol’s solution, 10 drops po TID. Given at least 1 hour after thionamide administration to prevent iodine being used as substrate for new hormone synthesis


low cortisol & low aldosterone

tired, fatigues

weight loss, anorexia
Hypovolemic, Hypotensive (on their way to shock)

and hyperpigmentation


most common cause of adrenal crisis

Severe, acute adrenocortical insufficiency

MC and most severe in pts w/ primary AI
i. loss of cortisol AND aldosterone function


precipitating factors for adrenal crisis

i. Dehydration
ii. Infection
iii. Trauma
iv. Surgery
v. Acute and abrupt withdrawal of steroids for AI or with long term use for another autoimmune disease
vi. Inadequate stress dosing with AI


presentation with adrenal crisis

i. Profound weakness or fatigue, LOC, AMS
ii. Nausea, vomiting, dizziness
iii. Abdominal/flank pain
iv. Diaphoretic, febrile, tachycardic, tachypneic
v. Hypotensive and volume depleted- the big problems
vi. Can rapidly progress to shock, seizures and coma


adrenal crisis ddx

i. Cholelithiasis
ii. Gastroenteritis
iii. Hypercalcemia
iv. Hyperkalemia
v. Hypoglycemia
vi. Hyponatremia
vii. Hypothyroidism/Myxedema coma
viii. Metabolic acidosis
ix. Hypopituitarism


how do you confirm a adrenal crisis

Serum electrolytes! (Hyponatremia and hyperkalemia, possible hypoglycemia and hypercalcemia- rare)

Serum cortisol, ACTH, renin (to confirm dx)
CBC w/diff , cultures (underlying infection)
TSH and FT4


Tx (initiated immediately! No waiting for results)

ii. Aggressive IV fluid replacement
1. 5% dextrose in normal saline solution (D5NS)
2. 1-3 liters within first 12-24 hrs based on volume status & urine output

Hydrocortisone 100mg IV bolus, or dexamethasone 4mg IV bolus

Mineralcorticoid replacement not necessary acutely because of saline infusion and steroid treatment

Frequent hemodynamic & electrolyte monitoring is crucial**


other than grave's disease what cause hyperthyroid

i. Other causes: toxic nodular goiter, thyroiditis, excess iodine intake, TSH producing adenoma


When would you switch fluids to 5% dextrose for a pt in DKA

b. When glucose reaches 200mg/dL, add 5% dextrose to saline


when can you start SC insulin instead of IV

1. Serum glucose <200mg/dL
2. Serum anion gap <12meq/L
3. Serum bicarbonate > 18meq/L
4. Venous pH > 7.30


HHS is different from type 1 because

- most commonly seen in >65yo with type 2 DM; insulin deficiency is present but NOT absolute, evolves more insidiously

a nonketotic state : the residual insulin secretion is sufficient to minimize ketosis but does not control hyperglycemia


why is HHS more dangerous

more severe neurological manifestations


reasons for HHS

inadequate insulin tx/noncompliance (21-40%)

acute illness/infection (32-60%)