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Endocrine Emergencies Part 2 SBA 1 You are a junior doctor working in A&E and have been asked to investigate a 24-year old female patient who is presenting with tachycardia and delirium. Basic observations show a heart rate of 120 bpm and a temperature of 38.8°C. She was diagnosed with Grave’s disease a few months ago. Blood results show: TSH – low A. Addisonian crisis T4 – very high B. Thyroid storm T3 - high C. Hypothyroidism D. Phaeochromocytoma What is the likely diagnosis? E. Myxoedemic coma SBA 1 You are a junior doctor working in A&E and have been asked to investigate a 24-year old female patient who is presenting with tachycardia and delirium. Basic observations show a heart rate of 120 bpm and a temperature of 38.8°C. She was diagnosed with Grave’s disease a few months ago. Blood results show: TSH – low A. Addisonian crisis T4 – very high B. Thyroid storm T3 - high C. Hypothyroidism What is the likely diagnosis? D. Phaeochromocytoma E. Myxoedemic comaThyroid Storm Thyroid Storm - Overview Causes of thyrotoxicosis? • Life threatening complication of thyrotoxicosis • Grave’s disease – MOST COMMON (hyperthyroidism) • Toxic nodular goitre • Similar TFTs to hyperthyroidism • Subacute thyroiditis (de Quervain’s) Symptoms: • Fever – usually >38.5°C • Tachycardia • Confusion/agitation or delirium • Nausea & vomiting • Can have abnormal liver function tests (LFTs) – sometimes jaundiced Thyroid Storm - Management Can be divided into supportive and specific management Supportive Specific • IV fluids • Hydrocortisone 200mg IV QID (for • Cooling adrenal insufficiency and decreases T4 release) • Paracetamol (do not give NSAIDS as can displace thyroxine from proteins) • Antithyroid drugs – oral propylthiouracil (1g loading dose and • IV propranolol then 250mg QID • After propylthiouracil blockade, give either sodium iodide, potassium iodide or Lugol’s Iodine SBA 2 You are on placement in A&E and have been asked to clerk a patient for the endocrinology consultant. You speak to John, a 31 year old male who mentions that he was diagnosed with Addison’s disease a few years ago Which of the following hormonal disturbances is related to this disease? A. Low cortisol B. Low thyroxine C. High thyroxine D. High cortisol E. Low prolactin SBA 2 You are on placement in A&E and have been asked to clerk a patient for the endocrinology consultant. You speak to John, a 31 year old male who mentions that he was diagnosed with Addison’s disease a few years ago Which of the following hormonal disturbances is related to this disease? A. Low cortisol (CORRECT) B. Low thyroxine C. High thyroxine D. High cortisol (Cushing’s disease) E. Low prolactin SBA 3 John’s partner is with him in A&E and mentions that he has recently stopped taking his steroids for his Addison’s since he didn’t notice any benefit. You conduct some basic observations and blood tests, noticing that he has become hypotensive, hypoglycaemic and very confused. What is the likely diagnosis? A. Myxoedemic coma B. Addisonian crisis C. Sick euthyroid syndrome D. Sepsis E. Hyperparathyroidism SBA 3 John’s partner is with him in A&E and mentions that he has recently stopped taking his steroids for his Addison’s since he didn’t notice any benefit. You conduct some basic observations and blood tests, noticing that he has become hypotensive, hypoglycaemic and very confused. What is the likely diagnosis? A. Myxoedemic coma B. Addisonian crisis C. Sick euthyroid syndrome D. Sepsis E. HyperparathyroidismAddisonian CrisisBackground – Adrenal Insufficiency Primary – also known Secondary Tertiary as Addison’s disease • Inadequate ACTH • Not enough CRH • Reduction in secretion stimulating adrenal released glands of cortisol and • Involves hypothalamus aldosterone • Low cortisol release • Usually caused by long • Most common cause is • Involves damage to term steroid use >3 autoimmune pituitary gland weeks • Damaged adrenal glandsBackground – Adrenal InsufficiencyAddisonian Crisis - Emergency • Acute and severe presentation of Addison’s disease Symptoms – reduced consciousness, hypotension, hypoglycaemia, hyponatraemia, hyperkalaemia Causes • Can be first presentation of Addison’s • Triggered by infection, trauma, or acute illness in Addison’s patients • Withdrawal of steroids after taking them for a long time SBA 4 You suspect John to be experiencing an Addisonian Crisis, what would you initially administer? A. IV or IM hydrocortisone B. IM adrenaline C. IV potassium chloride D. IV insulin E. IV potassium iodide SBA 4 You suspect John to be experiencing an Addisonian Crisis, what would you initially administer? A. IV or IM hydrocortisone B. IM adrenaline C. IV potassium chloride D. IV insulin E. IV potassium iodide Addisonian Crisis - Treatment Initially: • Hydrocortisone 100mg (IV or IM) stat • IV Fluid resuscitation - 1L normal saline over 30-60 mins (with dextrose if hypoglycaemic) • Monitor electrolytes Continue hydrocortisone 100mg every 6 hours until patient stable – oral replacement after 24 hours and reduced to maintenance over 3 to 4 days SBA 5 Jane is a 34 year old female who was recently diagnosed with a pituitary adenoma. She is currently 28 weeks pregnant. She has presented to A&E today with an extremely bad headache and slight visual disturbance You decide to conduct an MRI just to be safe and rule out anything serious (shown below) What is the likely diagnosis? A. Tension headache B. Subarachnoid haemorrhage C. Migraine D. Pituitary Apoplexy E. Cluster headache SBA 5 Jane is a 34 year old female who was recently diagnosed with a pituitary adenoma. She is currently 28 weeks pregnant. She has presented to A&E today with an extremely bad headache and slight visual disturbance You decide to conduct an MRI just to be safe and rule out anything serious (shown below) What is the likely diagnosis? A. Tension headache B. Subarachnoid haemorrhage C. Migraine D. Pituitary Apoplexy E. Cluster headachePituitary Apoplexy Pituitary Apoplexy - Basics • Haemorrhagic or non-haemorrhagic necrosis of pituitary gland Presenting Features Diagnosis Precipitating Factors • Headache (very similar to • MRI • Hypertension subarachnoid thunderclap) • Pregnancy • CT is insensitive unless • Vomiting there is frank intracranial • Trauma haemorrhage present • Neck stiffness • Anticoagulation • Oculomotor palsies Pituitary Apoplexy - Imaging Sagittal T1 MRI Coronal T2 MRI Axial T1 MRI GaillardF, CyriacJ,SharmaR,etal.Pituitaryapoplexy.Reference article,Radiopaedia.org(Accessed on26Mar2023)https://doi.org/10.53347/rID-1889 Pituitary Apoplexy - Imaging Sagittal T1 MRI Coronal T2 MRI Axial T1 MRI GaillardF, CyriacJ,SharmaR,etal.Pituitaryapoplexy.Reference article,Radiopaedia.org(Accessed on26Mar2023)https://doi.org/10.53347/rID-1889 Pituitary Apoplexy - Treatment Medical Management Surgical Management • Urgent steroid replacement due • Transsphenoidal pituitary gland to loss of ACTH decompression • Fluid balance • For those without vision loss or with normal consciousness, conservative management may be opted for SBA 6 Bill has come to see the GP for results of a recent blood test after he presented a few weeks ago with fatigue and sensitivity to cold. His TFT results are shown below: • TSH – high • T3 and T4 - low Which of the following conditions accounts for these results? A. Primary hyperparathyroidism B. Secondary hyperthyroidism C. Primary hyperthyroidism D. Primary hypothyroidism E. Secondary hypothyroidism SBA 6 Bill has come to see the GP for results of a recent blood test after he presented a few weeks ago with fatigue and sensitivity to cold. His TFT results are shown below: • TSH – high • T3 and T4 - low Which of the following conditions accounts for these results? A. Primary hyperparathyroidism BONUS QUESTION B. Secondary hyperthyroidism Where is the likely C. Primary hyperthyroidism site of pathology? D. Primary hypothyroidism (CORRECT) E. Secondary hypothyroidism SBA 7 Despite the GP advising Bill to start treatment for his hypothyroidism, he refuses. A few weeks later he presents to A&E with severe confusion and hypothermia What is the likely diagnosis? A. Pituitary apoplexy B. Addisonian crisis C. Myxoedema coma D. Hypocalcaemia E. De Quervain’s thyroiditis SBA 7 Despite the GP advising Bill to start treatment for his hypothyroidism, he refuses. A few weeks later he presents to A&E with severe confusion and hypothermia What is the likely diagnosis? A. Pituitary apoplexy B. Addisonian crisis C. Myxoedema coma D. Hypocalcaemia E. De Quervain’s thyroiditisMyxoedema ComaMyxoedema Coma Acute presentation of hypothyroidism – usually if patient has untreated hypothyroidism Presenting symptoms • Stupor (low consciousness) • Hypothermia • Respiratory failure • Confusion • ComaMyxoedema Coma - Diagnosis Diagnosis usually made with symptoms and a few tests Thyroid Function Test (TFT) Other blood results which may be • High TSH (95% cases – 5% deranged: central causes) • Hyponatraemia • Low T3 and T4 • Hypoglycaemia • Anaemia • Hypercholesterolaemia • High LDH • High CK Myxoedema Coma - Management Resuscitate: Other things to consider • Correct • Admit to ICU due to high hypoglycaemia if mortality present • Intubate if necessary (e.g. • If hyponatraemic, respiratory depression) consider cautious correction over time • IV fluids (<10mmol/L day) • Warm patientThank you for attending! Fill in the feedback form to get access to the slides! Upcoming Events: • Monday 3 April – Endocrine Pharmacology Part 1 • Wednesday 5 April – Endocrine Pharmacology Part 2 th • Monday 10 April – SBA Quiz