Inpatient Endocrine Emergencies

Michael Shannon, MD
Providence Endocrinology, Olympia WA
 Endocrine Inpatient Issues

„ Hyperthyroidism and thyroid storm

„ Myxedema coma
„ Non-thyroidal illness
„ Acute adrenal insufficiency
„ Hypercalcemia
„ Pituitary apoplexy
 Diabetes in Hospital Settings
„ Estimated that 18% of admissions have
diabetes, and that diabetics account for 24% of
the length of stay for all inpatient days
„ There is improved recognition that elevated
sugars are not benign from stress and lead to
(increasingly uncompensated) complications
such as urinary tract infections, poor wound
healing, and dehydration
 Thyroid Storm
„ Thyroid storm is an extreme form of
thyrotoxicosis (usually with a precipitating
cause – MI, infection)
„ Manifested by marked delirium, severe
tachycardia, dehydration, and very high fever;
„ Diagnosis is history and physical; labs show
very low TSH, high free T4 and T3 (TSH is
most reliable)

Franklyn JA, NEJM 1994.

 Hyperthyroid vs Thyroid Storm
„ Note that findings are not different than that of
hyperthyroidism, but the difference is in the
setting; key is fever (typically > 40 C / 104 F)
„ You can be admitted with hyperthyroidism that
is severe yet is not thyroid storm (hyperthyroid
tachyarrhythmias are serious but not “storm”)
„ Thyroid hormone levels are not much different
in storming than in other cases so likely other
predisposing factors (stress, metabolic factors)
 Etiology of Thyroid Storm
„ Most thyroid storm is
from Graves’ disease
„ Very small number
of cases from toxic
nodule or multi-
nodular goiter
„ Usually unstable for
scan; TSI Ab helpful
 Treatment of Thyroid Storm
„ This is an ICU level admission
„ Major part is supportive care with
hydration, cooling blankets, and
antipyretics (acetaminophen)
„ Avoid aspirin (case reports that it
releases thyroid hormone from its
binding globulin, worsens case)
„ Intensive therapy with anti-thyroid
drugs, beta-blockers, steroids,
iodine solutions
 Treatment of Thyroid Storm
1. Beta-blockade: propranolol 20-60 mg q6h (can
also give intravenously)
2. Anti-thyroid drugs: Usually methimazole used for
outpatients, but here PTU at high doses will both
lower synthesis and T4->T3 peripheral conversion;
150 mg q6hrs
3. Iodine agents
4. Steroids
 Treatment of Thyroid Storm
1. Beta-blockade
2. Anti-thyroid drugs
3. Iodine agents: utilize the Wolff-Chaikoff effect
where high dose iodine suppresses thyroid
hormone production (hard to find: SSKI drops or
Lugol’s solution – popular with naturopaths)
4. Steroids: dexamethasone 2 mg q6h to drop
circulating T3 levels and suppress T4 -> T3
conversion
 Myxedema Coma

„ Severe hypothyroidism with

metabolic shutdown (cardiac,
hepatic, other organs)
„ Often comatose or delirious
„ Dry coarse skin, hoarse gravelly
voice, thin dry hair
„ Hypothermia
„ Pericardial and pleural effusions
Myxedema: Pathophysiology
Myxedema: Diagnosis and Etiology
„ Diagnosis is made with clinical scenario and
TSH through the roof – usually >80
„ Can also have a very low free T4 with a
slightly elevated TSH if pituitary failure (rare)
„ Three major etiologies:
„ Undiagnosed hypothyroidism (autoimmune
thyroiditis, radiation hypothyroidism, etc)
„ More commonly discontinuation of therapy or
running out of medication (for months)
„ Iatrogenic: stopping patients for I-131 cancer Rx
 Myxedema Treatment
„ Initial therapy is supportive
„ Rewarming protocol
„ Support BP and respiration
(usually low-output CHF)
„ Levothyroxine: 250 mcg
intravenous x 3 days load,
then 100 mcg (or old dose)
orally per day
„ May use liothyronine
(Cytomel) 12.5 mcg TID
x3 days
 Nonthyroidal illness (NTI)
„ Also known as euthyroid sick syndrome; this
occurs when there is inhibition of the thyroid
deiodinase, reducing the levels of T3
„ This is “all levels down” thyroid pattern;
decreased TSH, decreased T4, decreased T3
„ Challenge is differentiating thyroid levels as a
result of illness versus the cause of it (classic
conundrum: manic episode with TSH 0.2)
Nonthyroidal illness: Lab Patterns
 Diagnostic Challenges: NTI
„ Low FT4: NTI versus hypothyroidism; use the TSH
„ Clinical signs, eg bradycardia, hypoventilation, hypothermia
„ >20 mU/ml: primary hypothyroidism
„ 5-20: primary hypothyroidism vs NTI; repeat in 1-2
weeks or treat empirically and reassess as outpatient
„ <5: NTI vs secondary hypothyroidism; History or
evidence of pituitary disease?
„ Low TSH: NTI vs hyperthyroidism; use the free T4
„ Clinical signs, including atrial fibrillation
„ Low-normal : probably NTI, especially if TSH >0.1
μU/ml
„ High: hyperthyroidism

For modest deviations – time is your friend!

Adrenal Insufficiency and Crisis
 Adrenal failure: Presentation

„ Weakness & fatigue „ Hyponatremia

„ Anorexia & weight loss
„ Nausea & vomiting
„ Dizziness and orthostatic
symptoms
„ Lethargy, stupor
„ Hypotension
„ Shock & death
„ Hyperkalemia*
„ Hyperpigmentation*

*Only in primary adrenal failure

Dusky Hyperpigmentation
 Adrenal failure: causes
„ Primary (cortisol & aldosterone deficient)
„ AUTOIMMUNE
„ tuberculosis, fungal infections

„ Hemorrhage, sepsis, etc

„ Secondary (ACTH & cortisol deficient)

„ GLUCOCORTICOID THERAPY
„ hypothalamic or pituitary lesions
 Adrenal failure: evaluation

„ Dexamethasone 10 mg IV if hypotensive
„ Cortrosyn stimulation test:
„ Cortrosyn 250 mcg IV
„ Plasma cortisol @ 60 min

„ Normal: >20 mcg/dL or stimulate > 9 mcg/dL

„ Not sensitive for new onset secondary adrenal

failure
„ Eg, after pituitary surgery, pituitary apoplexy
„ Treat empirically with prednisone for 4 weeks

„ Hold prednisone AM of test

 Adrenal failure:
emergency therapy
„ Indications:
„ Hypotension
„ Stupor/delirium
„ Severe abdominal pain and intractable nausea
„ Severe hyperkalemia or hyponatremia

„ Hydrocortisone 100 mg IV Q 8 hr
„ D5/normal saline to hydrate
„ Then double the outpatient dose for three days
„ Get them a Medic-Alert bracelet!
 Failures of Adrenal Treatment

Running out of meds, no sick day plan, no bracelet.

 Steroid coverage
„ Indications:
„ Known adrenal failure
„ Chronic steroid treatment
„ Recent (1 year) chronic steroid treatment (prednisone 7.5 mg/day
for two months in the last twelve)
„ For severe illness, major surgery:
„ Hydrocortisone 50 mg IV Q 8 hr
„ For moderate illness, minor surgery
„ Hydrocortisone 25 mg IV Q 8 hr
„ Post-op or during hospitalization, double dose for three
days then taper to chronic replacement over 2-3 days
 Hypercalcemia: Presentation

System Common--------------------------------Rare

CNS Fatigue, weakness, depression, confusion

GI Constipation, anorexia, N+V, pancreas

Renal Poly’s, dehydration, stones, calcinosis

Cardiac --------palp, rhythm, brady, short QT

 Hypercalcemia: Differential

Common Uncommon Rare

Primary HPTH Milk-Alkali Pheo, VIPoma

Malignancy Sarcoidosis FHH
Drugs (Li, VitD) Tuberculosis
Renal failure Histoplasmosis
TPN HypoAlkPhos
Thyrotoxicosis Immobilization
 Hypercalcemia: Malignancy
1. PTHrP (i.e. squamous cell carcinoma)
2. Cytokine release (i.e. multiple myeloma)
3. Lytic bone disease (i.e. breast cancer)
4. Excess Vitamin D production (i.e.
lymphoma)
 Hypercalcemia: When to Treat
„ Severe symptoms of hypercalcemia
„ Plasma [Ca] >13 mg/dl
„ Where possible send laboratories beforehand
„ Calcium with intact PTH
„ If PTH is anything but low or low-normal, it is
primary hyperparathyroidism
„ If malignancy, consider no treatment – there
are worse deaths than hypercalcemic delirium
(average lifespan is 6 weeks with this)
 Severe hypercalcemia: therapy
„ Restore ECF volume
„ Normal saline rapidly
„ Positive fluid balance >2 liters in first 24 hr
„ Saline diuresis
„ Normal saline 100-200 ml/hr
„ Replace potassium
„ Only after full volume repletion
„ Zoledronic acid 4 mg IV over 15 min
„ If plasma [Ca] >14 mg/dl or >12 mg/dl after rehydration
„ Monitor plasma calcium QD
Pituitary Apoplexy
 Pituitary Apoplexy
„ Hemorrhage into a pituitary adenoma; sudden
increase in pressure typically presents with
severe headache, nausea, vomiting
„ Severe headache usually leads to CT/MRI
showing pituitary mass with acute bleeding
„ This is a neurosurgical emergency if severe
enough, if the hemorrhage endangers optic
chiasm; need surgery unless prolactinoma
„ Goal is to check/replace steroids and thyroid
A hospital is no place to be sick.

Samuel Goldwyn (1882-1974)

 Question and Answer

Thank you for allowing me to review endocrine consult

issues and support your patients’ endocrine needs.