ENDOCRINE EMERGENCIES NANDALAL BAGCHI

CASE 1 40 YEAR OLD WOMAN ONE DAY AFTER GALL BLADDER 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 ANEMIA DEFICIENCY OF OTHER PITUITARY HORMONES PAST USE OF GLUCOCORTICOIDS HEADACHE VISUAL SYMPTOMS

CAUSES: PRIMARY,CHRONIC AUTOIMMUNE INFECTIONS: TBC,FUNGAL, HIV METASTATIC CARCINOMA ADRENOMYELONEUROPATHY ISOLATED GC DEFICIENCY

CAUSES: SECONDARY,CHRONIC 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 PROLONGED ACTH STIMULATION RENIN, ALDOSTERONE INSULIN HYPOGLYCEMIA METYRAPONE CRH STIMULATION TEST

TREATMENT HYDROCORTISONE IV 100MG FOLLOWED BY MG OVER NEXT 24H GLUCOSE SALINE 2-3L MONITOR ELECTROLYTES ORAL THERAPY IN 1-2 DAYS –HYDROCORTISONE –FLUDROCORTISONE

CASE 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 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

TREATMENT BLOCK HORMONE SYNTHESIS –PTU 150MG EVERY 6H BLOCK HORMONE RELEASE –SSKI 5-10 DROPS EVERY 8H BLOCK BETA ADRENERGIC SYSTEM PREDNISONE MG OVER 24H PLASMAPHERESIS, DIALYSIS FLUIDS, COOLING, NO ASA

CASE 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 mcg BOLUS, THEN 100 mcgDAILY AFTER 48H OR, TRIIODOTHYRONINE 12.5 mcg EVERY 8H