Sepsis minus a source? ADDrenal?

Adrenal Crisis Loss of mineralocorticoid and/or glucocorticoid production. Dysfunction is at level of pituitary (secondary or tertiary cause) or the adrenals (primary) with multiple causes:

• autoimmune

• suppression from exogenous hormone use

• hemorrhage

• tumor

• infection

Clinical picture:

• abdominal pain

• vomiting

• diarrhea

• hypotension

• refractory shock

• fever

• confusion

Chronic insufficiency will also give: weight loss, fatigue, arthralgia, myalgia, anorexia, mood change, syncope history, salt cravings, hyper pigmentation, vitiligo

Fever, shock, and confusion sounds like septic shock can labs help?

**for adrenal crisis a random cortisol level below 3 μg/dl (80 mmol/L) is diagnostic but will not be low in all cases

other labs you can expect to find, hypoglycemia, hyponatremia, hyperkalemia, elevated BUN creatinine, hypo-osmolarity

Treatment:

• supportive measures

• stress dose steroid hydrocortisone 100mg IV Q6

Bottom line -in your patients with refractory shock send cortisol level and give stress dose steroid

-consider this diagnosis in patients with autoimmune history, recently postpartum, chronic steroids, Sepsis with no source,

Disposition:

ICU

Cause You're Hot Then You're Cold

Today we will start a miniseries on endocrine emergencies. Myxedema coma -severe hypothyroidism Clinical Features: -Hypothermia -Hypoglycemia -Hypoventilation--> hypoxia, hypercapnia, -Hyponatremia in 50% of patients -Hypotension & bradycardia -Hypomentation, obtunded can conversely have psychosis -Myxedema, nonpitting edema due to deposition mucin & albumin --> can complicate airway -Seizure

Work up: -Work up other pathology -TSH (high) -T4 (low) -T3 (low) -Cortisol (to check for adrenal insufficiency)

Specific treatment: -Initial dose 200-400mcg T4(levothyroxine) IV then daily 50-100mcg IV -Plus initial dose 5-20mcg T3(liothyronine) then 2.5-10mcg every 8 hours,  continue T3 until patient stable -Optimal dose may be moderate dose, use lower doses in older frailer patients -Stress dose steroid hydrocortisone 100 mg every 8 hours

Disposition: ICU

Thyroid storm -too much thyroid, think elevated metabolism and stress response Clinical Features: -Tachycardia--> 60% patients have tachycardia or atrial fibrillation -CHF -Arrhythmia -Cardiac arrest -Hyperpyrexia often 104-106 -Agitation -Psychosis -May be obtunded or comatose -Hand tremor -Diaphoretic -Nausea, diarrhea, and vomiting

Work up: -TSH (low) -T3 (high) -T4 (high) may also have hyperglycemia, mild hypercalcemia, leukocytosis,

Specific treatment: (it is important to give betablocker before inhibiting thyroid hormone synthesis) 1. Propanolol 0.5-1mg IV over 3-5 minutes repeat every 5-10 minutes till heart rate <100 -OR use esmolol, load 250-500mcg/kg, infusion 50-100mcg/kg/min -CHF is high output still give test doses betablocker 2. PTU (propylthiouracil) load 600-1000mg then 300mg every 6 hours give PO, NG, PR (preffered in pregnancy) -OR use methimazole20-30 mg every 6 hours 3. corticosteroid, hydrocortisone 100mg IV every 8 hours -OR use Dexamethazone 2-4mg IV every 6 hours (dexamethazone does not scew cortisol tests) 4. inhibit thyroid production with inorganic iodine -Potassium Iodide: 5 oral drops -OR Lugol's solution 10 oral drops

Thyroid Storm-POD

THYROID STORM PRESENTATION

• Fever

• Altered mental status

• Tachycardia

CAUSES

• Infection

• MI

• DKA

• Pregnancy

• Trauma

• Untreated thyroid disease

• Ingestion of thyroid hormone

TREATMENT

• Control body temperature

  • Cool IV fluids, external cooling

• IV Fluids

  • High output cardiac failure- preload dependent

  • Add glucose as they have low glycogen stores

• Beta Blocker

  • Propranolol 0.5- 1mg IV over 3-5 minutes

    • Prevents conversion of T4àT3

    • Non selective beta blocker

    • Titrate to HR<100

  • Stop Thyroid hormone synthesis

    • Propylthiouracil 1000mg PO/NG or PR

      • Preferred in pregnancy

      • Prevents conversion of T4àT3

    • Hydrocortisone 100mg IV q 8

      • Blocks T4àT3

      • Thyroid storm causes depression of hypothalamic- pituitary axis

    • Iodine

      • Inhibits thyroid hormone release

      • Do not give for at least 1 hour after starting PTU

    • Antibiotics