ORALS - ENDOCRINE Flashcards
HYPERTHYROIDISM CASE SCRIPT
PRESENTATION: (hyperthermia, sepsis, AMS, AF, ABDO pain, N/V)
Bloodwork (CBC, ext chem, VBG) +
- TSH/T4/T3 (TSH undetectable)
- Cortisol
- Cultures
Calculate burch wartofsky score (>45 = storm)
mgmt:
1. supportive management – IVF, cooling and benzos
2. antibiotics
3. directed therapy
=>PTU 1g then 250mg Q4H
=>methimazole (20mg, bad in 1st trimester)
- Other therapies
=>propranolol 2mg IV (Consider esmolol, esp in HF)
=>lugols solution 10drops
=>hydrocortisone 100mg IV
=>cholestyramine daily
=>cooling
=>plasmapheresis (for refractory) - agitation
=>olanzapine or Haldol
**follow up questions **
1. What is the Burch Wartofsky score
Tachycardia / Precipitating event (ACS, MI, PE) / Mental status /Fever / GI/hepatic symptoms /CHF
45: thyroid storm / 25-44: impending storm / 25: unlikely
- Causes of hyperthyroidism
Graves disease
Amiodarone induced thyroiditis
Toxic adenoma
Toxic multinodular goiter
Autoimmune thyroiditis
Post partum thyroiditis
Thyroid carcinoma - Mechanisms of treatment
**Blocks TH synthesis **
=>PTU 500mg
=>Methimazole 20mg (iodine -> T4)
=>Lugals solution 1-2drops (also blocks RELEASE)
**Decr peripheral T4 T3 conversion **
=> PTU
=> Benzos (also ADRENERGIC tone)
=> Hydrocortisone 300mg IV
**Sequesters TH **
=> Cholestyramine 4g - Causes of thyroid storm (PTSSSD)
Pregnancy
Trauma - penetrating / blunt to gland, burns
Sugar - DKA, HSS, hypoglycemia /Surgery / Stress
Drugs - thyroid hormone, lithium
Infection, sepsis // Ischemia - MI, PE, CVA // Iodine - amiodarone, contrast - Why is ASA bad?
Displaces thyroid hormone off of thyroglobulin
increases free T4/T3
HYPOTHYROIDISM CASE
PRESENTATION: (rhabdo, brady, confusion, seizure, puffy eyes, large tongue, pericardial / pleural effusion)
Bloodwork (CBC, ext chem, VBG) + => HYPONA/GLC, HYPERCO2, HYPOTEMP
- TSH/T4/T3 (primary high TSH)
- Cortisol
- Cultures
- EKG
- CXR – pleural effusion
mgmt:
1. supportive management – IVF, warming
2. antibiotics
3. directed therapy
=>hydrocort 100mg Q8H
=>replacement: (old) – T4 500mcg / (young) – T3 20mcg
=>electrolyte abnormalities
=>treat rhabdo
follow up question
- causes of hypothyroidism
odine deficiency
lithium
Amiodarone
Trauma
radiation
thyroidectomy
pituitary adenoma, hemorrhage
Post partum - triggers of myxedema coma
CVA, MI
HyperCO2, hypoGLC
Cold, Sedatives
Inadequate replacement
GIB
Trauma
ADRENAL INSUFFICIENCY CASE
PRESENTATION: (volume deplete, hypotensive, weakness, N/V)
Bloodwork (CBC, ext chem, VBG) + => HYPOGLC/NA, HYPERK
- TSH/T4/T3
- Cortisol
- Cultures
- EKG – hyperK
- CXR
mgmt:
1. IVF
2. ABX
3. Directed therapy
- hydrocortisone 100mg IV Q8H (consider dex if not known to have AI)
- treat underlying cause
- electrolyte abnormalities
CONSULT – ENDO, ACTH stim test
follow up question
1. Causes of adrenal insufficiency
primary (adrenal):
Addisons
HIV
TB
CMV
Tumor
Adrenal hemorrhage
Adrenal tumor
secondary (brain)
Pituitary tumor
Pit surgery
Infiltrative dz to pituitary
TBI
Sheehan’s syndrome
- Triggers of adrenal insufficiency
Trauma
Sepsis
MI
Surgery
Steroid withdrawal
Volume depletion
Complications of steroids
Pigment changes
Immunodeficiency
Acne
Delayed wound healing
Psychosis
Hyperglycemia
DIABETES- DKA
Bloodwork (CBC, ext chem, VBG) + => GLC >11.1, PH 7.3, BICARB 18, ketones / BHB
- BHB or urine ketones
- VBG
- Cultures PRN
- EKG/CXR
- Chem/VBG Q2H + Accuchecks Q1H
mgmt:
1. volume + give IVF (10-20cc/kg over 30min)
2. potassium + UO
K 3.3 – no insulin, replace first
K 3.3-5.3 – replace with 40mEQ
K>5.3 – recheck, start insulin, NS 150cc/hr
3. Insulin – 0.1U/kg/hr
=>hold @ GLC = 11 / change fluid
=> D5W – Glc <11-15
4. Bicarb – if PH <6.9
5. Treat underlying cause
6. resolution – no acidosis, tolerate PO
CONSULT – ENDO
follow up questions
1. Triggers for DKA
Dehydration
Infection /sepsis
N/V – can’t tolerate PO
Missed medication
Ischemia
Intra-abdominal pathology
- Treatment of DKA complication - cerebral edema
HOB 30deg
3% NS 5cc/kg over 10min (mannitol 1g/kg IV over 15min)
Reduce insulin rate to 60%
Reduce maintenance fluids to 60%
Support airway PRN
CT head, neurosx, call ICU - Risk factors for cerebral edema
First presentation
Delay presentation
Peds 5yrs
Use of bicarb
Low bicarb
Insulin bolus
Treatment complication – hypoglycemia
BG <4 (adults)
Mgmt
- D50W IV 1amp, q15min recheck glucose
- change IVF => D5NS
- leave insulin infusion on, decr by 50%
DKA INTUBATION
Similar to ASA, physiologic difficult
Prepare for intubation
- Call ENT, anesthesia
- Ensure suction / O2 working
- Consider BVM as a pre-treatment
- Use operator with VL (as fast as possible)
- If patient is cooperative – consider awake
Optimize physiology
- Consider 2 amps bicarb
- Have phenyl / NE hanging for anticipated hypotension
- Match MV after intubation
HHS
Bloodwork (CBC, ext chem, VBG) + => GLC >33.3, BICARB >18, OSMOL >320, NO ketones / BHB, AMS
- BHB or urine ketones
- VBG
- Cultures PRN
- EKG/CXR
- Chem/VBG Q2H + Accuchecks Q1H
mgmt:
1. volume + give IVF
2. potassium + UO
K <3.3 – no insulin, replace first
K 3.3-5.3 – replace with 40mEQ
K>5.3 – recheck, start insulin, NS 150cc/hr
3. Insulin – 0.05U/kg/hr or patient’s home dose
5. Resolution – baseline mental status, normal OS, GLC, tolerating PO
CONSULT – ENDO
follow up questions
- Dx criteria for HHS
Glucose >33.3
Bicarb >18
Osmolarity >320
No ketonemia or ketonuria
Depressed mental status
