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AHD Group A Rounds
February 14, 2013
Endocrine Emergencies
Thyroid, Adrenal, Diabetic
Dr. Gary Greenberg MD FRCP EM
Objectives
• Review the common causes, clinical signs,
symptoms, pathophysiology and management of
the following metabolic emergencies related to
thyroid disease states, adrenal insufficiency and
diabetes:
• Thyrotoxicosis, thyroid storm, myxedema coma,
adrenal crisis, non ketotic hyperglycemic
hyperosmolar state and diabetic ketoacidosis,
hypoglycemia, New onset diabetes, diabetic
complications.
Case Example
• 32 yo female presents with new onset of
fatigue, palpitations, tremor, anxiety,
insomnia, exertional dyspnea, 20 lb wt loss.
• PHX: Appendicitis. Meds: none Allergies: none
• Examination: thin, anxious, BP 140/60, P 120
regular, EOM normal, no proptosis but has
non tender thyroid enlargement, no nodules.
• Chest/CVS/Abdomen all normal. Fine tremor
outstretched hand, reflexes brisk.
These are other symptoms of hyperthyroidism
except
• A) Heat intolerance.
• B) Fever
• C) Diarrhea
• D) Reduced appetite
Which is the most common cause of
hyperthyroidism at age < 50 ?
• A) Hashimotos Thyroiditis
• B) Graves Disease
• C) Multinodular Goiter
Graves Disease- Common findings except
• A) Pretibial myxedema ( mucopolysaccharide
deposition ).
• B) Ocular Abnormalities ( lid lag, proptosis,
diplopia).
• C) Thyroid Bruit
Tenderness of the thyroid gland is indicative of
• A) Graves Disease
• B) Hashimotos Thyroiditis
• C) Subacute Thyroditis
The following can induce hyperthyroidism
except
• A) Seaweed ingestion
B) IV Contrast agents
• C) Potato chips
• D) Amiodarone
• E) Lithium
The following tests should be done in suspected
thyrotoxicosis except
• A) TSH, Free T4, T3 levels.
• B) Thyroid ultrasound
• C) Thyroid nuclear scan
A thyroid scan in Graves Disease will show
• A) Decreased uptake of radioactive iodine
• B) Patchy uptake with hot nodules
• C) Diffuse uptake
Initial treatment of thyrotoxicosis may include
the following except
• A) Dexamethasone
• B) Propanolol
• C) Antithyroid drugs ( Propylthiouracil/
Methimazole )
• D) Radioactive Iodine ablation
Thyroid Storm requires all of the following
findings except
• A) Fever
• B) Tachycardia
• C) Altered Mental Status
• D) Diarrhea
The overresponsiveness of the sympathetic
nervous system is due to
• A) excessive circulating catecholamines
• B) Excessively elevated serum T3,T4 levels
• C) Unknown
Treatment of Thyroid Storm includes all except
•
•
•
•
•
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A) Treatment of fever
B) Supportive measures
C) Increase levels of thyroid stimulating hormone
D) Inhibit Thyroid hormone synthesis and release
E) Inhibit peripheral conversion of T4 to T3
F) Reduce thyroid hormone effects on adrenergic
state
Thyroid Storm- Diagnostic Criteria
• What are they ?
CASE
• 62 year old patient with long standing Grave’s
Disease, had onset of fever, cough for 2 days.
Presents with agitation, nausea, vomiting,
Temp. 38.2, HR 125/min, pedal edema.
• Does this patient have Thyroid Storm or just
Pneumonia?
The Burch –Wartofsky Scoring
System
• Describe the Scoring system:
Treatment Thyroid Storm
• Review the treatment of thyroid Storm.
HYPOTHYROIDISM
• Define this condition.
Common causes of Primary Hypothyroidism are
the following except
• A) Antithyroid drugs
• B) Autoimmune Disorders
• C) Previous radioactive Iodine treatment of
Graves Disease
Hypothyroidism
• Review the causes of
• PRIMARY HYPOTHYROIDISM
• SECONDARY HYPOTHYROIDISM
Classic Presentation of Hypothyroidism
includes all except
•
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•
•
•
A) Cold intolerance
B) Weight gain
C) Dry puffy skin around the eyes.
D) Galactorrhea
E) Slow movements
Hypothyroidism
• List the signs and symptoms of severe
hypothyroidism.
These lab tests are helpful in
Hypothyroidism except
• A) T 3 level
• B) T4 level
• C) Elevated cholesterol
• D) TSH
These are found in Myxedema Coma except
• A) Temperature is often < 32 degrees C.
• B) Patients often shiver.
• C) Dysfunction of Thermoregulatory Center.
All are important tests to do in Myxedema Coma
except
•
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A) Chest x-ray
B) EKG
C) ABG
D) Serum Calcium
E) Serum Cortisol
F) CK
All are part of the Diff. Dx of Myxedema Coma
except
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A) Hypothermia.
B) Respiratory failure.
C) CO2 Narcosis.
D) Hyponatremia.
E) Cocaine overdose.
F) CHF
G) Stroke
H) Narcotic overdose
I) Hypoglycemia
MYXEDEMA COMA- Clinical Findings
• What are they?
MYXEDEMA COMA- Treatment
• What is the treatment for Myxedema coma ?
Adrenal Insufficiency
• Definition of this condition:
All the following are causes of Primary Adrenal
Insufficiency except
A) Idiopathic- ( autoimmune adrenalitis)
B) Infiltrative disease ( Sarcoid )
C) Adrenal Hemorrhage/ Infarct
D) Steroid therapy
E) Granulomatous infectious ( TB, Fungal )
F) Metastatic involvement ( lung, breast, colon)
G) Bilateral Adrenalectomy
All the following are causes of Secondary
Adrenal Insufficiency except
A) Chronic suppression by exogenous steroids.
B) Ingestion of Rifampin.
C) Withdrawal of steroids too rapidly
D) Head trauma
E) Hypothalamic tumors
F) Pituitary tumors
All may be found in Primary
Adrenal Insufficiency except
• A) Hyperpigmentation of palms, creases,
nipples.
• B) Stiff ears with hard nodules in males.
• C) Long toe nails.
Adrenal Crisis
• What are the signs and symptoms of Adrenal
Crisis?
Adrenal Crisis
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The following are present except:
A) Hyponatremia
B) Hyperkalemia
C) Hypercalcemia
D) Hypoglycemia
E) Azotemia ( BUN )
F) Metabolic Alkalosis
G) Low voltage EKG
ACTH Stimulation Test
• What is this test and how is it administered?
Treatment of Adrenal Crisis
• What is the treatment of Adrenal Crisis?.
Diabetes
• Describe some common presentations of
complications of diabetes.
DIABETES
• Definition:
Case
• 50 year old male , presents with new onset of
diabetes- weight loss, polyuria, polydypsia,
increased appetite, fatigue.
• Blood glucose 22.0, no acidosis, no ketones in
the urine.
• VS stable
NEW ONSET DIABETES
• How would you treat the newly diagnosed
diabetic in the ED?
• What choice of Medications do you have?
• How do those medications work?
Diabetic Ketoacidosis
Describe the key findings of Diabetic
Ketoacidosis and how are they manifested
Physiologically?
Common factors for DKA -except
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A) Infection
B) MI
C) Stroke
D) Cocaine use
E) Hyperthyroidism
F) Pancreatitis
G) Trauma
H) Non compliance with Insulin in diabetic
Physical exam
• What are the physical findings in diabetic
ketoacidosis?
Lab Findings
• What are the lab findings?
DKA
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Discuss the treatment rational for the use of
A) Insulin
B) Sodium Bicarbonate
C) Potassium
D) IV fluid
Treatment of DKA
• Objectives: what are they?
Excessive NaHCO3 administration can lead to all
but
•
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A) Spinal Fluid Alkalosis.
B) Hypokalemia
C) Impaired O2 / Hb dissociation
D) Rebound Alkalosis
E) Na overload.
Non Ketotic Hyperglycemic Hyperosmolar Coma
• What are its predominant features?
Precipitants can be any of the following except
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A) Pneumonia
B) MI
C) Stroke
D) Pulmonary Embolus
E) Pancreatitis
F) Water intoxication
G) GI bleed
H) Medications ( Thiazides, dilantin, lasix)
NKHHC
• What is the difference in treatment of the Non
Ketotic Hyperglycemic Hypersomolar patient
vs the DKA ?
HYPOGLYCEMIA- The following are
causes of hypoglycemia except
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A) Alcohol.
B) ASA.
C) Hemodialysis.
D) Lack of caloric intake.
E) Sulfonylureas.
F) Gastroparesis
G) Insulinomas
Signs and Symptoms of
Hypoglycemia are except:
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A) Sweating.
B) Increased urination
C) Weakness.
D) Confusion.
E) Anxiety
F) Tachycardia
Hypoglycemic treatment options
include except
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A) Glucagon.
B) Dextrose 50 %
C) Orange juice
D) Bread