Treatment of Severe Hypothyroidism

We do not see patient's with severe hypothyroidism often, but it is important that they be treated aggressively. Some treatment pearls are

• Rule out aggravating cause (i.e.: infection [UTI, pneumonia], myocardial infarction)
• Start IV levothyroxine dosing
  • Initial dose 400-500 mcg. This is a large dose but it only saturates the thyroid receptors and will not cause a rebound hyperthyroidism state.
  • Daily dose 100 mcg/day
• Consider starting Dexamethasone/hydrocortisone
  • Patients may also have adrenal insufficiency from primary pituitary failure or may have secondary adrenal suppression due to the severe hypothyroidism.  If dexamethasone/hydrocortisone is not provided they may develop severe adrenal insufficiency once you kick start their metabolism.

 

Diabetic Ketoacidosis Treatment:

• At least at our academic medical center, we find it very hard to get a DKA patient admitted to an ICU or IMC while they are still in DKA.  Typically, we can correct the acidosis and downgrade them to a floor bed before their ICU/IMC bed is available.
• Some key points to remember when managing DKA in the ED.
  • The mainstay of treatment for the hyperglycemia initially is IV fluids.
  • Check labs often and replete Magnesium and Potassium early.
  • Insulin should not be started until the potassium is confirmed to be >3.3 mEq/L
  • Patients can still be in DKA even though there glucose is normal.
  • Intravenous insulin must be continued until all the ketones are cleared. 
  • Add D5W or D10 if needed to ensure that their glucose levels stay up but do not stop the insulin.
  • Patients need to receive a long acting insulin (i.e.: Lantus or NPH) 2 hours before the insulin drip is stopped.  Placing a patient only on Sliding Scale Insulin will almost guarantee that they go back into DKA on the floor.
  • Typically you can just restart the patients home long acting insulin, but if you are leary about hypoglycemia if they are not eating well, then give them 3/4 their home dose.

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Medical Treatment of Hyperparathyroidism

• Hyperthyroidism will typically only need to be treated in the Emergency Department when they present with Hypercalcemia. 
• Outpatient management of hyperthyroidism consists of serial PTH measurements, Calcium, and Creatinine.
• Hypercalcemia should be treated with normal saline hydration. 
  • Once the patient is determined to be euvolemic you can enhance diuresis and excretion of calcium by giving the patient furosemide. 
  • Remember hydrochlorathiazide can actually increase serum calcium by preventing its excretion.
  • This patients should receive 4-10 liters of normal saline in the first day.
  • You can also give bisphosphonates and calcitonin. 
  • For high calcium levels with mental status changes consider hemodialysis.

Hyperparathyroidism results in elevated PTH and typically results in elevated calcium levels (hypercalcemia). 

• Primary hyperthryoidism is due to hyperfunction of the parathyroid glands, while secondary hyperthyroidism is a reaction of the parathyroid glands to hypocalcemia caused by another etiology, most commonly chronic renal failure. 
• Tertiary hyperthyroidism is due to hyperplasia of the parathyroid glands due to loss of response to serum calcium levels and this too is seen in chronic renal failure

Though most cases are asymptomatic, symptomatic patients can present with:

• weakness and fatigue
• depression
• aches and pains
• decreased appetitie
• constipation
• polyuria and polydipsia
• kidney stones
• osteoporosis.

Treatment options to be discussed next week....Stay tuned.

Apathetic Hypothyroidism AKA Hypothyroidism in the Elderly

Remember that elderly do not present with classic signs and symptoms of hypothyroidism, but rather it is more common for them to have atypical presentations.

Things that make the diagnosis more difficult in the elderly are:

• The thyroid gland is often difficult to palpate.
• Symptoms like weight gain, cold intolerance, and mental and physical decline are often attributed to the normal aging process.
• Symptoms are often attributed to medications, or medications mask some of their symptoms.

Consider the diagnosis in elderly patients with:

• Arrthymias
• New onset dementia or increased “forgetfulness”
• Depression
• Failure to thrive
• Anemia
• Hyponatremia

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Cushing Syndrome

The most common cause of Cushing syndrome is the use of exogenous glucocorticoids, and it is rarer to have a problem with the hypothalamic-pituitary-adrenal axis.

These patients can present with:

• proximal muscle weakness
• easy bruising
• weight gain
• hypertension
• diabetes
• impaired immune function
• infertility or menstrual irregularities

For the emergency department we need to be worried about those on chronic steroids that can not increase their native steroid production in a time of stress which will lead them to adrenal crisis.

Pearls for those with Cushing Syndrome:

• May have perforated viscous with minimal peritoneal signs
• Suspectable to fungal infections so consider adding fluconazole to those that are septic
• Give a large dose of hydrocortisone 100mg PO/IV every 8 hours if you suspect adrenal crisis.