R1 Lightning Lecture – Thyroid Storm (Dr. Perling):
- Thyroid storm: “extreme hyper metabolic state caused by increased thyroid hormone”
- Most commonly caused by Graves disease
- Burch-Wartofsky Point Scale is a tool that can help point to thyroid storm, though be cautious as it can be nonspecific (sepsis, etc.)
- Tx: active cooling if hyperthermic (can give Tylenol too); beta blocker > PTU/methimazole > steroid > wait 1 hour > iodine (in that order)
- Manage other concomitant conditions accordingly: i.e. amio for a-fib, benzodiazepines or olanzapine for agitation
R1 Lightning Lecture – Addison’s and Cushing’s disease (Dr. Hudson)
- Addisons = low steroids, Cushings = high
- Addisons: usually autoimmune, “low” symptoms like hypotension, weight loss, fatigue, hyperpigmentation
- Tx: lifelong corticosteroid replacement (hydrocortisone)
- Adrenal crisis – give high dose corticosteroid, treat hypotension and glucose as needed
- Cushings: chronic exposure to excess corticosteroids, “big” symptoms like weight gain, buffalo hump
- Cushing syndrome (problem with gland) vs Cushing disease (problem with brain)
- Dx and management is usually inpatient/outpatient (not in ED): need urine 24 hour cortisol level, treat sequelae in ED as needed (glucose, electrolytes)
R2 Small Group Cases (Dr. Beard)
- Case 1 – DKA: look for hyperglycemia, ketones, acidosis. Watch potassium and rapid fluid administration (cerebral edema)
- Case 2 – HHS: severe hyperglycemia usually without ketones; high serum osmolality. Treat with aggressive fluids. Mortality much higher than DKA.
- Case 3 – Adrenal crisis: consider in patients with unexplained hypotension, watch electrolytes (hyponatremia, hyperkalemia), give corticosteroids.
- Case 4 – Myxedema coma: hypothyroidism, mental status change, hypothermia, +/- precipitating factor (infection, med noncompliance). Tx with levothyroxine, corticosteroid, passive warming, and precipitating cause (sepsis).
R3 Case Review (Dr. Hill-Norby)
- Pre-Eclampsia: new onset hypertension in pregnancy (usually > 20 wks or up to 4 wks post-partum)
- Diagnosis made by BP + proteinuria, or based on BP and presence of end-organ damage (severe features) without proteinuria
- Treat BP with labetolol, hydralazine, or nifedipine
- Treat seizures with magnesium!
- Needs urgent delivery
- Severe Hyponatremia – usually symptomatic < 120
- If seizing w/ known hyponatremia -> 3% hypertonic saline bolus (around 150cc), can use sodium bicarb amp if do not have hypertonic saline easily
bh372z