Thyrotoxic crisis (thyroid storm) It is sudden acute exacerbation of all of the symptoms of thyrotoxicosis, presenting as a life-threatening syndrome.

This is a medical emergency with a mortality of 10% despite early recognition and treatment. Precipitating factors 1. infection in an untreated hyperthyroid patient 2. ill-prepared patient undergoing thyroidectomy 3. within few days of I131 therapies Clinical features 1. Fever often associated with flushing and sweating 2. Tachycardia, AF, high pulse pressure, and occasionally heart failure 3. Marked agitation, restlessness, delirium and coma 4. Nausea, vomiting (causing volume depletion and shock), diarrhea and jaundice Management 1. Control CVS symptoms: Propranolol is rapidly effective orally (80 mg 6-hourly) or IV (15 mg 6-hourly). 2. Block release of thyroid hormone from the gland: Na ipodate (500 mg daily orally) restores serum T3 levels to normal in 4872 hrs by inhibiting release of hormones and conversion of T4 to T3. 3. Inhibit synthesis of new thyroid hormone Oral carbimazole (4060 mg daily). In the unconscious patient, carbimazole can be administered rectally. 4. Dexamethasone (2 mg 6-hourly) 5. Supportive measures: Reduce fever by cooling blankets and paracetamol (aspirin is contraindicated) Supportive measure for heart failure If no response do plasmapheresis or PD Withdraw Na iopodate and inderal after 10-14 days but continue on carbimazole.

Myxoedema coma This is a rare presentation of hypothyroidism in which there is depressed consciousness, usually in an elderly patient who appears myxoedematous. Precipitating factors 1. drugs such as phenothiazine 2. cardiac failure 3. chest infection Clinical features 1. body temperature may be as low as 25 C 2. hypoventilation (causing hypoxia and hypercapnea) and bradycardia 3. dilutional hyponatremia, hypoglycemia, hypocortisolism 4. progressive stupor, convulsion Management 1. Tri-iodothyronine (T3) is given as an IV bolus of 20 g followed by 20 g 8-hourly until there is sustained clinical improvement. After 4872 hrs, oral thyroxine (50 g daily) may be substituted. 2. Hydrocortisone (100 mg 8-hourly) is given in secondary hypothyroidism 3. Other measures: slow rewarming IV fluids broad-spectrum antibiotics high-flow oxygen

Acute severe hypercalcemia (malignant hypercalcemia) Clinical features 1. abdominal pain 2. vomiting, dehydration, hypotension 3. pyrexia and altered conscious level Management 1. Admission with no immobilization 2. Rehydration with normal saline: In very ill patient forced diuresis with normal saline [4-6 liters] + furosemide [20-100 mg every 1-2 hours] will increase calcium loss in urine by 5001000 mg/day and decrease serum calcium by 2-6 mg/dl after 24 hours. 3. Bisphosphonates (sometimes): pamidronate [90 mg IV over 4 hours] causes a fall in calcium which is maximal at 2-3 days and lasts a few weeks unless the cause is removed; follow up with an oral bisphosphonate 4. Glucorticoids: prednisolone [40 mg daily] is usually useful in hypercalcemia of malignancy 5. Other additional therapies include calcitonine and haemodialysis 6. In rare instance when serum calcium is greater than 18 mg/dl the lifethreatening hypercalcemia can be rapidly but transiently lowered by neutral phosphate [500 ml 0.1 M IV every 6-8 hours]

Adrenal crisis Precipitating factors 1. intercurrent disease or infection 2. abrupt withdrawal of steroids 3. Waterhouse-Friedrichsen syndrome, anticoagulation therapy Clinical features 1. 2. 3. 4. hyponatremia, severe hypotension and shock hypercalemia with muscle cramps hypoglycemia, unexplained fever nausea, vomiting, diarrhea

Management 1. Hydrocortisone hemi-succinate [100 mg IV] and continued [100 mg IM hourly] until the gastrointestinal symptoms abate before starting oral therapy 2. IV fluid as normal saline and 5% dextrose if hypoglycemic 3. The precipitating cause should be sought and if possible treated Advices to patients with adrenal insufficiency 1. The patient must have steroid card 2. During intercurrent stress e.g: febrile illness, double the dose of hydrocortisone. 3. During minor operation 100 mg hydrocortisone by IM with premedication must be given. For major operation hydrocortisone 100 mg every 6 hour for 24 hours later on 50 mg IM every 6 hourly should be given. 4. If Addisons disease has gastroenteritis, cortisol replacement must be changed to parentral hydrocortisone if unable to take it by mouth.

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