High TSH and Low T4 - primary hypothyroidism Others Mild anaemia Hypercholesterolemia Elevated hepatic enzyme levels Elevated prolactin level Hyponatremia secondary to extracellular volume expansion produced by an elevated antidiuretic hormone level Blood glucose levels may be normal to low as a result of decreased gluconeogenesis and reduced insulin clearance.

1. Myocardial infarction 2. Infection 3. Sepsis 4. Stroke 5. Pulmonary embolism 6. Prolonged exposure to cold 7. Exposure to drugs that suppress the central nervous system 8. DKA

High mortality 90% Occurs 6-8 hours into correction of hyperglycaemic state Consider if acute drop in GCS / coma Severe headache Pupil changes BP changes Seizures RF First diagnosis \<5yrs Initial pH \<7.1 and CO2 \<18 Aggressive IVF ? HCO3 infusion Mx Supportive + ABCs Head up 30 degrees Mannitol 1-2g/kg or 3% saline 5-10ml/kg Decrease IVF rate to 1/3 No role of steroids CT head

Endocrine Flashcards by Sonal Shah

Thyrotoxicosis - Causes

Primary
- Grave’s
  - Most Common, younger F:M 10:1
  - ABs bind TSH-R and stimulate TSH production/release
- TMN
  - Second most common, >50yrs, milder
  - Can present acutely if iodine deficient pt receives iodine load
- Toxic adenoma
Thyroiditis
- Painful
  - De Quervain syndrome
  - Suppurative
- Not painful
  - Trauma
  - Drug - amio /Li / iodine
  - Infection
  - Autoimmune
  - Radiation
  - Subacute / subclinical /
Postpartum thyroiditis
Exogenous / Factitious
Secondary (rare)
- Pituitary adenoma, Ectopic/metastatic thryrdoid tissue

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Thyrotoxicosis - Eye signs

Stare
Exophthalmos
Lid lag
Proptosis
Increased tearing / irritation
Peri-orbital oedema
Limited superior gaze

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Thyroid Storm Treatment

ABCs
Step 1 - Beta blocker
- Propanolol 0.5-1mg IV q15min
- Sympathetic surge
Step 2 - Stop T4 → T3 production
- PTU 500-1000mg PO/NG/PR
- Methimazole 20-30mg
Step 3 - Inhibit T3/T4 release
- Potassium iodide 5 drops
- Lugol solution 4-8 drops
- NB only 1 hr after Step 2 (can worsen Sx)
Step 4 - Inhibit peripheral T4 → T3 conversion
- Hydrocortisone 300mg IV
- PTU and propanolol also do this
Supportive
- ABCs
- ABx
- Cooling /Benzos for agitation / IVF / Glucose

Additional interventions
Cholestyramine
Blocks enterohepatic recirculation of thyroid hormone
Dose: 4 g PO Q6 hours
L-Carnitine
Blocks entry of thyroid hormone into cells
Dose: 1 g PO Q12 hours

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Thyroid Storm - Clinical criteria

Fever
Tachycardia
AMS
CCF
GI
Ppt event

Burch-Wartofsky Scale

Score > 45 high likelihood, 25-44 impending, <25 unlikely

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Thyroid Storm - precipitants

Untreated / undiagnosed or non-compliant + stressor => thyrois storm

Systemic - trauma, infection/sepsis, surgery
Endocrine insult - DKA, HHS
Drug induced
CVS - MI, CVA, PE,
OBS - labour, pre-eclampsia
Radioactive iodine

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Hypothyroidism Causes

Primary causes:

Idiopathic atrophy (95%) of cases.
Iatrogenic (ie post radioactive iodine or surgery)
Congenital, (agenesis)

With goitre (reduced thyroid hormone and elevated TSH):

Iodine deficiency - commonest cause globally
Chronic thyroiditis
- Hashimoto’s
- Pregnancy / Post-partum
- Infection
- Surgery
- Trauma
- Radiation
Drugs
- Iodine / amio / Li
- Non-compliance

Secondary Causes: (rare)

Pituitary disease
Hypothalamic disease

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Hypothyroid - Bloods

High TSH and Low T4 - primary hypothyroidism

Others

Mild anaemia
Hypercholesterolemia
Elevated hepatic enzyme levels
Elevated prolactin level
Hyponatremia secondary to extracellular volume expansion produced by an elevated antidiuretic hormone level
Blood glucose levels may be normal to low as a result of decreased gluconeogenesis and reduced insulin clearance.

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Myxodema Coma - Clinical findings

Hypothermia
Hypotension - refractory
Hypoventilation - T2RF
Bradycardia
AMS - lethargy to stupor to coma
Myxoedema - puffy eyelids, large tongue, broad nose, legs
Metabolic
1. Low Na, glucose

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Myxoedema PPt

Myocardial infarction
Infection
Sepsis
Stroke
Pulmonary embolism
Prolonged exposure to cold
Exposure to drugs that suppress the central nervous system
DKA

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Myxoedema Crisis - Rx

Supportive

ABC
IVF
- May need fluid restriction for low Na
Rx hypogylcaemia
Hypothermia - passive warming
IV hydrocortisone 100mg
Rx underlying ppt

Specific

Thyroid hormone replacement
- T3 - 20mcg IV or 10mcg IV if old or Hx of CVD/arrhthmia
- T4 - 200-400mcg IV then 75-100mcg daily

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Interpreting Thyroid tests

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Diabetes diagnostic criteria

HbA1C >6.5%
Fasting glucose >7.0mmol/l
Random glucose >11.1mmol/l AND Sx
OGT glucose >11.1mmol/l

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Serum osmolality

275-295 mOsm/kg

2[Na+] + glucose/18 +BUN/2.8

Estimated

2[Na] + glucose + urea

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Corrected Sodium

135-145

[1.6 x (glucose -5.6)] /5.6

Estimated

Na + (glucose -5 /3)

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Cerebral Oedema

High mortality 90%
Occurs 6-8 hours into correction of hyperglycaemic state
Consider if
- acute drop in GCS / coma
- Severe headache
- Pupil changes
- BP changes
- Seizures

First diagnosis
<5yrs
Initial pH <7.1 and CO2 <18
Aggressive IVF
? HCO3 infusion

Supportive + ABCs
Head up 30 degrees
Mannitol 1-2g/kg or 3% saline 5-10ml/kg
Decrease IVF rate to 1/3
No role of steroids
CT head

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DKA Mx and Therapeutic End Points

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Resuscitate
- Correct hypotension / bradycardia
- No insulin until K+ >3.3mmol
Repair/Replace
- Volume repletion
  - Fluid deficits >100ml/kg
- Correct electrolyte imbalances
- Insulin 0.1unit/kg/hr
- Rx ppt cause
- Prevent complications
- VTE Prevention
Reassess
- Ongoing BSL / ketone / K monitoring
- Add 5% dextrose when BSL <15mmol
- K+ replacement
  - > 5.5 - no replacment
  - 4-5.4 - 10mmol /hr
  - <4 - 20mmol /hr
  - <3.3 - stop insulin and replace K+

Therapeutic Goals

Ketones 0.5mmol/hr
HCO3 - 3mmol/hr
BSL - 3mmol/hr
K+ - 4-5mmol

Resolution

Clinical improvement
BSL <11.1
Ketones < 0.6
VBG pH > 7.3

HHS

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Hyperglycaemia >30mmol
- Ketones <3
- Acidosis pH>7.3, HCO3 >15
Hyperosmolarity >320 mOsm/kg
Dehydration
AMS

Resuscitate
Rx underlying cause
IVF
- Fluid deficit 100-220ml/kg
- Aim 50% deficit in first 12 hours
  - 0/9% Saline 1l.hr for first few hours
  - If Na corrected(serum osmolality) responding then continue at slower rate
  - If Na corrected high then switch to .45% Saline
Electrolyte repletion
- K / Mg / PO4
- K+ supplementation as per DKA
BSL
- Insulin 0.1u/kg/hr
- Lower by 3mmol/hr
- When BSL <15
  - Insulin 0.05u/kg/hr
  - Dex/Saline
ICU/Endocrine
VTE prophylaxis

DKA vs HHS

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Hypercalcaemia

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Serum levels >3mmol/l symptomatic

Calc:

Sx: Stones, Bones, Moans, Groans

Signs: ECG - short QT interval

Excretion

IVF
LOOP diuretic (thiazide makes worse)
Dialyse

Osteoclast inhibition (dec Ca release)

Bisphosphonate - Pamidronate 90mg IV
Calcitonin - PRN for cardiac dysrhythmias - takes 24-48 hrs to work

Adrenal Insufficiency Causes

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PRIMARY - high ACTH, low cortisol (hence hyperpigmentation)

Chronic
- Autoimmune (Addison’s)
  - Post infectious - HIV, CMV, MAC, TB,
- Congenital adrenal hyperplasia
- Post-infectious
- Metastatic - breast/lung Ca
- Infiltrative
- Bilateral adrenalectomy
- Drugs - rifampicin, etomidate, ketoconazole
Acute
- Haemorrhage /infarction
  - Meningooccaemia (Waterhouse - Friedrichson’s)
  - Anticoagulants
  - Anticardiolipin AB syndrome
  - Trauma

SECONDARY - severe stressor

Chronic
- Pituitary - tumour, surgery
- Drugs
  - Chronic steroid use
  - MAB therapy
- Infiltrative - TB, sarcoid, eosinophilic granuloma
Acute
- Pituitary apoplexy
- Sheehan’s (post-partum pituitary necrosis)
- TBI
- Relative - sepsis, hepatic failure, severe pancreatitis, trauma)

Hyponatraemia Causes

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Def

Na+130 -135 mmol/L - mild
Na+125 -129 mmol/L - moderate
Na+< 125 mmol/L - severe
AMS, lethargy, confusion => seizures, coma

Causes

Hypovolaemia - dehydration
Water retention - failures - heart, kidney, liver, hypothyroid, psychogenic polydipsia
Salt loss - duiretics
Cerebral Salt wasting

SIADH

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Essential criteria:

Hyponatraemia
Hypotonic - dec serum osmolality < 275mOsm/kg
Urinary Na > 30 mmol/l
Clinical normovolaemia
No failures - cardiac, hepatic, renal
Not drug related

Causes

Tumours
1. Lung - oat cell. bronchogenic
2. Blood - leukaemia, lymphoma, thymoma
3. Pancreatic
Neurologic
1. Trauma
2. Infection
3. GBS
4. Autoimmune - SLE
5. AIDS
Pulmonary
1. Pneumonia, TB, Abscess
2. PPV
Drugs
1. Antidepressants - Fluoxetine/Amitriptyline, paroxetin
2. Carbamazepine

Tests
Low serum osmolality
Urine osmolality > 100mOsm/l (impaired water excretion)

Urine Na > 30mmol/l

Urine vs Serum osmolality

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In context of hyponatraemia:

Serum osmolality - if > 280 mosm/kg indicates spurious causes

hyperproteinaemia / hyperlipidaemia
hyperglycaemia / methanol / mannitol

Urine osmolality

•if serum hypo-osmolality confirmed +

Urine osmlolality < 100 mosm/kg

complete and appropriate suppression of ADH
causes
primary polydipsia
reset osmostat syndrome

Urine osmolality > 100 mosm/kg

indicates impaired water excretion
causes
hypothyroidism
adrenocortical insufficiency
hypovolaemia
renal /hepatic / cardiac failure
SIAD

Urinary Na+

< 20 mmol/L usually indicates hypovolaemia
> 30 mmol/L is suggestive of SIADH

Sodium Correction

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Seek and treat underlying cause

Euvolaemia - fluid restrict

Hypovolaemia - Volume replacement IV saline

3% Saline for treatment/prevention seizures

Consider loop diuretic to increase free water loss

Na correction

Acute hyponatraemia or chronic severe - rapid correction

•Na < 115

increase [Na+] 5-8mml/L in 30-60min.
then increase [Na+] 5-8 mmol/L each day for next 48-72 hours

•Na > 115

-aim to increase 5-8mmol/L each day for 48-72 hours

Sodium dose

•amount of Na+necessary to raise the serum [Na+] to 125 mmol/L approximated by

Na = (125-Na) X TBW x 0.6

•where Na+ is in mmol/L, TBW is total body water in (L) = body weight x 0.6

Phaeochromocytoma

Rare neoplams of adrenal medulla (90%) or SNS (10%) Rare cause secondary HTN Clinical features of xs catecholamines Episodic - HA, sweating, pallor, flushing, tachycardia / palpitations HTN / OH CNS - anxiety GIT - N/V/ wt loss Ix Metanephrine levels 24 urinary catecholamines / VMA Imaging - CT /MRI Mx **Alpha blockade prior to BB** - Prazocin 1-2mg PO or phentolamine IV 5mg - BB - Labetalol / propanolol - Endocrine / surgical / oncology referral

Endocrine Flashcards

(25 cards)