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An Endocrine Emergency
Dr.R.Ganesan
PG in Internal Medicine
History
C/O loss of consciousness -5 daysC/O cough and expectoration-1 monthNo c/o fever convulsion vomiting/head ache weakness of UL &LL facial asymmetry sedative/narcotics abuse
• Not a k/c of DM/SHT/CAD
• Known case of hypothyroidism past 15 years not on treatment past 2 years
• Non smoker/alcoholic
Vitals
• BP:IIO/80mmHg
• PR:60/min
• RR:18/min
Examination
• Unconscious• Temp:97F• Dry scally skin• B/L non pitting pedal edema• Pallor• Macroglossia• Bed sore
CNS
• GCS: E-2 M-4 V-3=9/15
• Pupils size 4mm reacting to light
• OCR present no occular bobbing/dipping• DTR: absent
• Plantar: extensor
• No neck stiffness
• Fundus examination normal
• CVS: S1,S2+,no murmur
• RS:NVBS,b/l crepts+
• Abdomen: Soft, no organomegaly
Investigations
CBC• Hb-7.6g%• TC-10200cells/cmm• DC:P35%,L60%,E5%• ESR:15/38mm• Platelet:1.8lak/cmm
• PS for anaemia Dimorphic anaemia
• Reticulocytic count-2%
• RFT:Urea-24mg%,creat-0.9mg%
• RBS-77mg%
• UrineR/E-normal
Lipid profile
• T .CHO:163
• TGL:230
• LDL:95
• HDL:36
• VLDL:32
• ECG:sinus bradycardia rate 58/min, old AWMI, low voltage complex
• CXR:Normal• ECHO:Mild concentric LV ,
Hypokinesia of IVS,LV anterior wall , LV apex,mild LV systolic dysfunction, noPE
• CT-brain:Normal
TFT
• FT3:17.2 ng/dl [80-200]
• FT4:1.39 micg/dl [4.6-12]
• TSH:68.8 mIU/ml [0.27-4.2]
• LFT: WNL
• HIV-negative
Electrolytes
Na 106 116 125 129
K 4 3.6 3.9 4.1
• Sputum c/s-klebsiella grown in culture sensitive to Amikacin,Ciprofloxcin
• Urine c/s-no organism grown
• Blood culture-no organism grown
Diagnosis
• Myxedema crisis
• Euvolumic hyponatremia
• CAD-old AWMI
• Anaemia
• Lower respiratory tract infection
Treatment
• Passive warming• Thyroxin:0.1mg 5 tab stat, 2 tab/day• Hydrocortisone:50mg tid• 3% Normal Saline• Antianginal drugs• Atarvostatin:10mg 2 HS• IV Antibiotics• Packed cell transfusion
Myxedema Crisis
• Common disorder of older age group
• Womens 8% >Men 2%
• Mortality rate>50% without treatment, >25% even with treatment
Neurologic manifestation
• Myxedema coma is misnomer absence of coma does not exclude the diagnosis
• Lethargy,stupor,delirium may be manifestation of myxedema coma
• The exact mechanism causing changes in mental status not known
Cardiovascular Manifestations
• Bradycardia / decreased contractility
• Decreased stroke volume
• Increased systemic vascular resistance
• Increased capillary permeability
• Pericardial effusion
Renal Manifestation
• Decreased GFR
• Decreased Na reabsorption
• Impair free water excretion• Hyponatremia
GI Manifestions
• Decreased intestinal motility
• Gastric atony
• Megacolon
• Paralytic ileus
• Malabsorption
Pulmonary Manifestation
• Respiratory muscle dysfunction
• Depressed ventilatory drive
• Obstructive sleep apnea syndrome
• Pleural effusion
Precipitating factors
• Infections
• Cold environment
• Trauma/Burns• Cerebrovascular accident
• GI bleed
• Drugs:sedatives,anesthetics,narcotics, diuretics, lithium,amiodarone, rifampin
Thyroxin Replacement
• GI-absorption is very low-IV therapy is mandatory
• T4 or T4+T3 or T3• Because deiodinase conversion of T4
to active T3 is reduced T3 administration may be advisable
• T3 immediate action and short t1/2 more likely to cause arrhythmias
• IV loading dose 500micg T4 followed by 50-100micg/day until patient is able to take medication by oral
• Elderly pt and pt with CAD full doseT4 may worsen myocardial ischemia
• Yong pt with low cardiovascular risk T310-20micg every 8-12 hours
Stress Steroid Replacement
• Adrenal insufficiency associated with hypothyroidism
• Thyroxin precipitate adrenal crisis• Hydrocortisone 5-10mg/hr
Warming
• Active warming: rapid and external rewarming are contraindicated
• Passive warming:using ordinary blankets and warm room
Infections
• Overt or occult infection precipitate myxedema crisis
• Fever and elevated WBC count are usually absent
• Pan culture and initiate empiric broad spectrum antibiotics
Predictors of survival
• Hypotension and bradycardia at presentation
• Need of mechanical ventilation• Hypothermia not responding to
treatment
• Sepsis
• Lower Glasgow Coma Scale
Complications
• Adrenal crisis: if not treated with concomitantly with stress dose of IV corticosteroids
• Myocardial infarction:may be precipitated by IV thyroxin
Follow-up
• Primary hypothyroidism:Assess TSH level every 6 weeks and adjust T4 dose
• Secondary hypothyroidism:Monitor FT4 level,measurement of TSH not usefull
THANK U