w. heath giles, m.d. university of tennessee college of ... · icu endocrine emergencies author:...

W. Heath Giles, M.D.University of Tennessee College of Medicine ChattanoogaAssistant Professor of SurgeryAssociate Residency Program Director

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Understand the presentation, work-up, and treatment of endocrine emergencies encountered in the ICU

Adrenal Insufficiency

Thyroid Storm

Hypercalcemia

Father of Endocrine Surgery

Nobel Prize 1909 (Thyroid)

Director of Surgery Clinic at Berne

Instructed military doctors

Produced most extensive research on gunshot wounds and the basis of the modern ideas of the mode of action of small caliber missiles with high initial velocity.

Primary (Addison’s disease) Adrenocortical disease

Both cortisol and mineralocorticoid deficiency Secondary Pituitary (ACTH)

Abrupt withdrawal glucocorticoids

Cortisol deficiency only Tertiary Hypothalamus (CRH)

Cortisol deficiency only

Symptoms

Weakness/fatigue

Anorexia

Nausea/vomiting

Myalgia/arthralgia

Headaches

Depression

Postural dizziness

Physical Exam

Hypotension

Tachycardia

Fever

Increased pigmentation

Laboratory findings

Hyponatremia

Hyperkalemia

Hypoglycemia

Hypercalcemia

Eosinophilia

Clues

Hemodynamic instability despite adequate fluid resuscitation

▪ Hyperdynamic circulation

▪ Decreased SVR

Ongoing evidence of inflammation without obvious source not responsive to empiric tx

Treatment Large bore IV access Serum electrolytes, glucose, cortisol, ACTH Bolus 2-3 liters NS or D5NS If no previous diagnosis adrenal insufficiency

▪ Dexamethasone 4mg IV

If known diagnosis ▪ Hydrocortisone 100mg IV

Correction electrolytes Supportive measures

Rare but life-threatening Graves’ Disease, TMNG, Solitary toxic adenoma Can occur in patients with long-standing

untreated hyperthyroidism but often precipitated by acute event Surgery

Trauma

Infection

Acute iodine load

Parturition

Pathophysiology unclear

Rapid rate of increase in serum thyroid hormone

Increased responsiveness to catecholamines

Enhanced cellular responses to thyroid hormone

Mortalilty: 20%

Presentation Tachycardia

Fever (104 – 1060)

CNS dysfunction▪ Agitation, delirium, coma

GI symptoms▪ N/V, abd pain

Tremor

Goiter

Exophthalmos

Warm and moist skin

Elderly Toxic goiter

New onset CHF/afib

Diagnosis

Thyrotoxicosis

▪ Elevated free T4/T3

▪ Suppressed TSH

Nonspecific

▪ Hyperglycemia

▪ Hypercalcemia

▪ Abnormal LFT

Burch HB, Wartofsky L. Life-threatening thyrotoxicosis. Thyroid storm. Endocrinol Metab Clin North Am 1993; 22:263

Treatment Supportive care

▪ IVF or diuretics for CHF

▪ Cooling blankets and Acetaminophen (NOT ASA)

▪ Treat precipitating condition

Beta blocker ▪ control increased adrenergic tone

▪ Propranolol 60-80 mg PO Q4-6hrs

▪ Esmolol

▪ *Calcium Channel blocker if unable to take BB x

Treatment

Thionamide▪ block new hormone synthesis

▪ PTU 200mg PO Q4hrs (also blocks peripheral T4T3)

▪ Methimazole 20mg PO Q4-6hrs

Iodine solution ▪ block release of hormone

▪ Lugol’s solution 10 drops Q8hrs

▪ SSKI 5 drops Q6hrs

▪ *wait at least 1 hr after thionamidex

x

xx

Glucocorticoids

▪ reduce T4T3 conversion

▪ Hydrocortisone 100mg IV Q6hrs

Surgery▪ If unable to take thionamide and

need urgent correction of hyperthyroidism

x

Causes Hyperparathyroidism

Malignancy

Thyrotoxicosis

Milk alkali syndrome

Hypervitaminosis D

Lithium

Thiazide diuretics

Adrenal insufficiency

Theophylline toxicity

Presentation GI

▪ Constipation▪ Pancreatitis▪ PUD

Neuropsychiatric▪ Anxiety▪ Depression▪ Lethargy▪ Confusion▪ Coma

Renal dysfunction▪ Kidney stones▪ ARF▪ Nephrogenic DI

CV▪ Shortened QT▪ Arrhythmia▪ HTN▪ Cardiomyopathy

Musculoskeletal▪ Weakness▪ Bone pain▪ Fracture (osteoporosis)

Mild (Calcium < 12 mg/dl)

No immediate treatment necessary

Avoid aggravating factors

▪ Thiazides

▪ Volume depletion

▪ Inactivity

▪ High Ca diet

Moderate (Calcium 12-14 mg/dl)

If chronic and mildly symptomatic avoid aggravators

If acute rise with change in sensorium treat as severe

Severe (Calcium > 14 mg/dl)

Volume expansion with isotonic saline 200-300 ml/hr

Loop diuretic only for renal failure and CHF

Calcitonin 4 IU/kg

Zoledronic acid 4mg IV over 15 min

Cooper and Stewart. Corticosteroid Insufficiency in Acutely Ill Patients. NEJM, Feb 2003.

UpToDate Morita, Dackiw, and Zeiger. Endocrine Surgery. 2010 Cameron. Current Surgical Therapy. 8th Ed. Townsend et al. Sabiston Textbook of Surgery. 17th Ed.