Download ENDOCRINE EMERGENCIES

ENDOCRINE EMERGENCIES
NANDALAL BAGCHI
CASE 1
• 40 YEAR OLD WOMAN
• ONE DAY AFTER GALL BLADDER
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SURGERY
NAUSEA , VOMITING
EXTREME WEAKNESS
HYPOTENSION, POOR RESPONSE TO
FLUIDS AND PRESSORS
SERUM K-5.5, Na-120
CLINICAL CLUES: PRIMARY
• HYPERPIGMENTATION
• HYPERKALEMIA
• VITILIGO
CLINICAL CLUES:
SECONDARY
• PALE SKIN WITHOUT MARKED
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ANEMIA
DEFICIENCY OF OTHER PITUITARY
HORMONES
PAST USE OF GLUCOCORTICOIDS
HEADACHE
VISUAL SYMPTOMS
CAUSES: PRIMARY,CHRONIC
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AUTOIMMUNE
INFECTIONS: TBC,FUNGAL, HIV
METASTATIC CARCINOMA
ADRENOMYELONEUROPATHY
ISOLATED GC DEFICIENCY
CAUSES:
SECONDARY,CHRONIC
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TUMORS
SURGERY, IRRADIATION
LYMPHOCYTIC HYPOPHYSITIS
GRANULOMAS
CHRONIC GC THERAPY
CRH DEFICIENCY
CAUSES: ACUTE
• ADRENAL HEMORRHAGE/NECROSIS
[SEPSIS, BLEEDING]
• POSTPARTUM NECROSIS OF THE
PITUITARY
• PITUITARY APOPLEXY
• HEAD TRAUMA
LABORATORY DIAGNOSIS
• BASELINE ACTH, CORTISOL
• COSYNTROPIN TEST
• MRI PITUITARY[ SELECTED CASES]
PRIMARY VS. SECONDARY
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PROLONGED ACTH STIMULATION
RENIN, ALDOSTERONE
INSULIN HYPOGLYCEMIA
METYRAPONE
CRH STIMULATION TEST
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
CASE
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30 YEAR OLD WOMAN
ADMITTED WITH PNEUMONIA
MILDLY DISORIENTED
TEMP. 103, PULSE 150/MIN
THYROID ENLARGED
TREMOR, BRISK DTR, WARM MOIST
SKIN
THYROID STORM:
DIAGNOSIS
• EVIDENCE OF SEVERE
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HYPERTHYROIDISM
END ORGAN FAILURE: CNS,CVS
MAJOR STRESSFULL EVENT
TFT CONSISTENT WITH OVERT
HYPERTHYROIDISM
A CLINICAL DIAGNOSIS
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
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BLOCK BETA ADRENERGIC SYSTEM
PREDNISONE 30-40 MG OVER 24H
PLASMAPHERESIS, DIALYSIS
FLUIDS, COOLING, NO ASA
CASE
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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
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
DIAGNOSTIC PROBLEMS
• HYPOTHERMIA HAS MANY CAUSES
• COMA HAS MANY CAUSES
• INFECTION IS HARD TO RECOGNIZE
PREDISPOSING FACTORS
• INFECTION
• DRUGS: ANESTHETICS, OTHER CNS
DEPRESSANTS
• HYPOTENSION e.g. GI BLEEDING.
• CARDIAC CAUSES: MI,CHF
• PROLONGED COLD EXPOSURE
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