Escolar Documentos
Profissional Documentos
Cultura Documentos
Objectives
By the end of this presentation, participants will be able to: Review diagnosis and treatment of thyroid emergencies Discuss diagnosis and management of adrenal insufficiency
Focus on steroid tapering
Case #1
66 y.o. woman for elective cholecystectomy Type 1 Diabetes and hypertension Rx: Ramipril 5 mg, Insulin Post Op Day 1 develops Temperature 38.7, HR 125 bpm (sinus), and confusion What is the differential diagnosis, most likely diagnosis and management
Differential Diagnosis
Hypoglycemia Hypoxia Pulmonary embolism Myocardial ischemia Sepsis Alcohol withdrawal Atelectasis Malignant hyperthermia/neuroleptic malignant syndrome
Uptodate 2012
An iodine solution to block the release of thyroid hormone AT LEAST ONE HOUR AFTER THIONAMIDE
Lugols solution 10 drops tid
Steroids to reduce T4-to-T3 conversion, promote vasomotor stability, and possibly treat an associated relative adrenal insufficiency
Hydrocortisone 100 mg tid
Thyroid Storm
Suspect it Review History Complete Physical Exam Appropriate blood work Management
Case #2
83 yo F found at home with decreased LOC Very drowsy BP 100/60, P 48, Temp 34.3, O2 sat 96% RA, BG: 5.1 Chest clear, HS: distant Swollen ankles GCS 9/15 PERL, face symmetrical, no papilledema Withdraws all 4 limbs Plantars downgoing Neck not stiff
Differential Diagnosis
Metabolic coma
Hypoglycemia, hyperglycemia, hypoxia, Hypotension, hypertension, hypothermia Organ failure (liver, renal, pulmonary, other ???) Drug intoxication / withdrawal Electrolyte abnormalities ([Na], [Ca], [Mg], [PO4], [H+]) Subarachnoid hemorrhage, encephalitis/meningitis Sepsis Postictal Endocrine: hypopit, hypoadrenal, hypothyroid
Myxedema Coma
Severe hypothyroidism with multiple systems involved Rare, high mortality Usually from chronic untreated hypothyroidism or acute precipitant
Meds (opioids), Infection, MI, Cold exposure
Adrenal Disorders
Prepared by: Drs Jeannette Goguen, Robert Silver and Jeremy Gilbert
Case 3
A 25 yo woman is brought to ER: c/o vomiting, diarrhea and abdominal pain x 24 hrs. Decreased appetite, lost 5 kgs involuntarily Significant dizziness on arising Retained her suntan from the previous summer
Case 3 continued . . .
O/E: she looks chronically unwell HR120/minute; BP is 90/60 supine and 60/30 upright Her JVP is not visible Diffuse abdominal tenderness with no peritoneal signs Large, dark freckles over her cheeks and darkened palmer creases Large patches of vitiligo Preliminary labs: Na=125, K= 5.2, glucose = 2.5.
The differential of weight loss and malaise is very broad, and includes:
Malignancy Endocrine: Diabetes mellitus, thyrotoxicosis Organ failure (liver, kidney) Inflammatory disorders Infections (eg, TB)
Baseline cortisol = 88 nmol/L (next day) Baseline ACTH = 100 (normal < 20) (1 month later) Formal Cortrosyn stim test: 1 hr cortisol= 120 (next day)
Cortisol level over 500-550 nmol/L at either baseline or 60 minutes post-injection of Cortrosyn and A rise in Cortisol of 250 nmol/L above baseline. (baseline cortisol > 500 nmol/L rules out adrenal insufficiency)
3. How would you differentiate primary from secondary (pituitary failure) adrenal insufficiency (AI)?
3. How would you differentiate primary from secondary (pituitary failure) adrenal insufficiency (AI)?
Primary AI Hyperpigmentation? Yes Other autoimmune Often disorders Evidence of pituitary No insufficiency/mass effect Hyponatremia? Yes Hyperkalemia? Yes ACTH level High Secondary AI No Rarely
Maybe
Yes No Low
Once hemodynamically stable and able to eat, stress dose steroid coverage can be aborted and oral administration of Hydrocortisone can begin
5. What advice for long-term management of AI would you give after discharge?
5. What advice for long-term management of AI would you give after discharge?
Hydrocortisone- 25 mg daily in split doses, try to reduce to lowest tolerated dose, typically 10 mg QAM, 5 mg QPM (dose is weight-dependent) Florinef- 0.1 mg daily Meds must be taken every day. For a mild febrile illness, double the dosage of Hydrocortisone for 3 days then see doctor if still unwell. If persistently nauseated or vomiting, go immediately to a local emergency room for intravenous glucocorticoid steroid Get a Medic Alert bracelet Purchase injectable Dexamethasone for remote travelling
Steroids
Glucocorticoid dosing equivalences
cortisone acetate 25 mg hydrocortisone (Solucortef) 20 mg prednisone 5 mg methyl-prednisolone (Solumedrol) 4 mg dexamethasone (Decadron) 0.75 mg
Steroid tapering
Steroids suppress the H-P-A axis based on duration, potency, dose
Likely if on prednisone 20 mg or its equivalent for more than 3 weeks or who looks Cushingoid Unlikely if on steroids for < 3 weeks or on alternate day regimens Uncertain if prednisone 10-20 mg for < 3 weeks or
If uncertain and going for surgery, it may be worth checking their HPA axis via ACTH stim test Individuals vary in how tapering affects them (age, ethnicity- slower in Blacks, elderly)
Consider stability of disease and general health status
Tapering-alternate days
If prednisone between 20-30 mg, can try alternate days at 10 mg by reducing by 5 mg every 1-2 weeks Decrease alternate day dose by 2.5 mg every 1-2 weeks until the alternate day dose is 0 mg Reduce the other dose as you would on a daily regimen
Case 4:
Mrs S is a 55 yo woman with kidney stones who has been found to have a right 4 cm adrenal mass on routine CT She has a past 1-year history of hypertension, BP today is 165/108 on:
Amlodipine 10 mg daily Ramipril 10 mg daily
3. What lifestyle factors can contribute to poorly controlled hypertension? Dietary: salt, alcohol, licorice Lack of exercise Obesity with sleep apnea Over the counter meds: pseudoephedrine, NSAIDs Cocaine, amphetamines
Case Continued. . .
Mrs S has a family history of dangerous tumors in the adrenal gland: both her father, paternal uncle and cousin had these removed. It had been recommended to her that she get her urine tested for adrenaline and that she consider genetic testing, but she has felt well overall and has been too busy with her law practice to get the testing done.
Case 5
75 yo M brought by EMS to ED as wife noted patient had decreased LOC O/E dry MM, BP 100/50, HR 110 Chest clear, Normal CVS, abdo Normal Ca+ 3.3, creatinine 125, albumin 29
Management?
Symptoms
Bones: fractures, osteoporosis, osteitis fibrosa, arthritis Stones: renal stones, polyuria, polydypsia (DI), nephrocalcinosis, renal insufficiency Groans: constipation, nausea, pancreatitis, peptic ulcer disease, abdo pain Moans: lethargy, depression, fatigue, stupor, coma Neuromuscular: proximal muscle weakness, myopathy Cardio: bradycardia, shortened QT, hyperT
Non-PTH Mediated
Hypercalcemia Ddx
Non-PTH Mediated
Malignancy
PTHrP (SCC) Osteolysis (myeloma, breast Ca) 1-alpha hydroxylase of Vitamin D (lymphoma)
Hypercalcemic Crisis: Rx
1. Volume: IV NS 300-500 cc/h (slower if elderly, cardiac or renal disease) 2. Loop diuretic: Only give if ECFv overloaded. Lasix 20-40 mg IV q4-6h. Monitor I/O carefully, keep patient in positive fluid balance
3. Replace electrolyte depletion from saline diuresis as needed (K, Mg, Pi, etc.)
Hypercalcemic Crisis: Rx
Calcitonin
1 IU SC test dose: skin rxn by 15 min 4 IU/kg SC/IM q12h If no response by 24-48h increase to max dose 8 IU/kg q6h Rapid effect (begins 4-6h) but transient (2-3d) due to tachyphylaxsis Effective in 60-70% of cases, lowers Ca by 0.3-0.5 mmol/L
Hypercalcemic Crisis: Rx
Bisphosphonates
Pamidronate Ca < 3.0 mM: 30 mg in 500cc NS IV over 4h Ca > 3.0 mM: 60-90 mg in 500cc NS IV over 24h Effect peaks @ 2-4d, lasts 1-6 wk (can retreat q1-6wk) Can also use zoledronic acid
Useful in Vitamin D intoxication, granuloma, lymphoproliferative disorders Prednisone 40-80 mg/d Takes 5-10d to see treatment effect
Steroids
Hypercalcemic Crisis: Rx
Obsolete treatments:
Mithramycin: + + N/V & other toxicities Gallium nitrate: nephrotoxic Chelators: IV EDTA, IV or PO phosphate
Consider dialysis
Identify & Rx underlying cause of hypercalcemia!
TREATMENT- Summary
Summary of Objectives
Review diagnosis and treatment of thyroid emergencies Discuss diagnosis and management of adrenal insufficiency
Focus on steroid tapering
Thank you!!!!
QUESTIONS??????