Endocrine Disorders (Kuzel)

• Hyperthyroidism:
• I.e. Graves Disease (most common), Toxic Multinodular goiter, Thyroiditis, Hashimotos (initially hyperthyroid, followed by hypothyroid) 
• Thyroid storm:
  • 15-50% mortality with tx (80-100% without) 
  • How they die: cardiac dysrhythmias, CHF, hepatic failure, hypotension, cardiovasc collapse
  • Tx: beta blocker (propranolol), thioamide (TPU/methimazole), steroid, iodide; avoid NSAIDs since they increase peripheral thyroid hormone conversion
  • PTU is Preferred because it has earlier onset and safe in Pregnancy 
• Hypothyroidism:
• Most commonly autoimmune, thyroiditis, iodine deficiency, post-ablation, panhypopituitarism 
• Euthyroid sick syndrome = low thyroxine syndrome w/ low or normal TSH, seen in critically ill pts
• Myxedema Coma:
  • 30-60% mortality
  • Often precipitated d/t sepsis, CHF, CVA, hypoxia, ACS
  • SLOW and SWOLE sx = bradycardia, hypotension, hypothermia, myxedema 
  • Tx: steroid, levothyroxine (be careful of dysrhythmias, ACS – give if hypotensive/altered)
• TSH can be helpful in NH patients w/ rapid decline and sx of hypothyroidism, & septic patients w/ refractory shock

Case Review (Loche, McGowan)

• AV fistula – most commonly in anterior forearm/upper arm, needs time to mature (6-12 mo) 
• Eval: should feel thrill; if you don’t feel thrill/pulse, assume thrombosis (get US/doppler) 
• AV fistula bleeding management:
  • Pinpoint pressure, can use bottle cap over bleed to let it clot off, use other adjuncts prn (surgicel, TXA, gelfoam)
  • Figure of 8 suture – DO NOT tie off vessel (damages fistula), just suture the superficial skin with non cutting suture 
  • If heavier bleeding, then do purse string suture 
  • If successful, have them move arm around, make sure it doesn’t rebleed, observe 1-2 hours
  • If you had to suture it or if any other major problems, you should give vascular surgery a call 
• Fistule thrombosis – loss of bruit/thrill, palpable clot
  • Management: Discuss with vascular, may or may not need emergent intervention, may get balloon angioplasty or thrombolysis 
• Pseudoaneurysm/aneurysm – bulging of vessel in outer wall (pseudo) or all layers (true) – get ultrasound, talk with vascular 
• Infection – much higher risk, especially if deeper infxn, need admission for IV abx, call vascular 

Supplements (Huecker) 

• Kefir should be first food of day – lots of good probiotics and vitamins 
• Daily supplement essentials: magnesium!, sunshine/VitD, vit K2, vit C, and iodine 
• Mag threonate is Huecker’s favorite form, oxide is trash; at least 200mg of elemental Mg/day 
• Labdoor.com is a good third party supplement tester
• Vitamin D: Most people need 3000-5000 IU in winter time, or 20 min in sun (if arms, legs, face exposed)
• Vitamin K2: helps prevent fractures, cancer incidence, neurocognitive fx 
• Fish oil: higher ratio of omega 3:6 is better, eating fish is best way to get it

Wernicke/Korsakoff (Blair)

• Wernicke = acute neuro change from thiamine deficiency = triad of encephalopathy, oculomotor dysfunction, gait ataxia 
• Korsakoff = chronic sx = antero/retrograde amnesia, confabulations, confusion, apathy 
• Thiamine important in energy production, lipid metabolism
• Most often d/t insufficient intake (alcoholism, starvation/anorexia, etc.), but also from malabsorption, increased metabolic requirements
• Tx: give thiamine (before glucose if they need that too), also give magnesium (as they’re usually hypomagnesemic)

Pheochromocytoma (Mattingly)

• Increased catecholamines d/t rare tumor in adrenal medulla
• Associated with familial syndromes (MEN 2A and 2B)
• Presentation: only 50% are symptomatic with episodic headache, tachycardia, diaphoresis
• Low vs high risk workups, but overall looking for (urine or plasma) metanephrines and catecholamines, if positive then get CT adrenal protocol or PET (usually inpatient side) 
• Treat hypertensive crisis with alpha-blockade (phenoxybenzamine or phentolamine), nitroprusside, or nicardipine; don’t give beta-blocker d/t risk of unopposed alpha activity! Eventually need tumor resection
• Be aware in ED of tumor recurrence even after tumor resection; avoid meds that cause crisis (BB, glucagon, histamine, reglan, corticosteroids)

Pharmacology in Hyperglycemic Crisis (Loudermilk) 

• Be aware of long vs short acting insulin > regular insulin drip is what’s used in DKA 
• Oral/injectable diabetic medications: biguanides (metformin), sulfonylureas (-zides), TZDs (pioglitazone), SGLT2i (jardiance), DPP4 (januvia), GLP-1 agonists (ozempic, trulicity) 
• DKA management: IV fluid therapy with 15-20 mL/kg over 1 hour
• Current protocol does NOT have insulin bolus, so just start the drip 
• Bicarb drip not recommended unless pH < 6.9
• Current order set is only “MED DKA”, but we will soon have ED specific DKA order set includes fluids, insulin gtt, K replacement, labs/VBG/vitals 

Pediatric Seizures (Isacoff) 

• Focal/partial (with or without impairment of consciousness) vs generalized seizures
• ABG/VBG in post-ictal patients not normally helpful – it’s already going to look bad even if not having respiratory failure
• BVM more favorable if still unconscious but starting to wake up, try not to intubate unless absolutely necessary 
• Look for metabolic derangements: sodium, glucose
• Management: ABCs, fyi: succinylcholine contraindicated in suspicion for muscular dystrophy, use roc or vec 
• Anticonvulsant tx for seizure > 5 min: rectal diazepam (home), intranasal versed (0.2mg/kg max 5), or IV ativan (0.1mg/kg up to 4mg)… treat with benzo x3 times, then phenytoin/fosphenytoin or phenobarbital; consider pyridoxine (vit B6) in kids < 1 with refractory seizures 
• Consider CT/MRI if signs of increased ICP, focal/persistent seizure

Diabetic Emergencies (Kuhl)

• 500+ million people affected by diabetes in world
• Common physician pitfalls: delayed ID of DKA, insulin therapy mistakes
• DKA = hyperglycemia + ketones + acidosis (bicarb < 15 or pH < 7.3) 
• HHS = glucose > 600, serum osm > 320, absence of ketoacidosis, presence/absence of coma no longer part of diagnosis 
• Don’t really need ABG/VBG to diagnose DKA (it costs ~ $300), utilize your serum bicarb instead
• End tidal CO2: low for DKA (<21, 100% specific) (d/t increased RR), high then not in DKA (>35, 100% sensitive)
• IV fluid choice: LR better in septic and medicine patients (SMART trial), no significant difference in ICU patients (SALT trial); large boluses of NaCl in DKA has risk of hyperchloremic metabolic acidosis
• Insulin drip 0.1 units/kg/hr going until ketoacidosis is resolved (normalization of pH, bicarb, and closure of anion gap)… NOT guided by blood glucose 
• K management: losing K d/t osmotic diuresis or falsely elevated as it’s extracellular but not in cells; if <3.5 then hold insulin, add in IVF, 3.5-5.5 then start insulin but also give K in IVF, if  >5.5 then just start insulin and no need to supplement
• Pseudohyponatremia – Na decreases by 1.6 for every 100 increase in glucose 
• Most common cause of DKA in US is med nonadherence, infection is 1st outside of US
• Euglycemic DKA possible with SGLT2i
• Consider D10 instead of amp of D50, less caustic and better outcomes

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