Endocrine emergencies



SAQ THYROID STORM - JB

A 42-year-old man is brought to your ED by ambulance with acute confusion. His wife states that he is previously well & on no medications, but his health has been deteriorating for three months, with tiredness & 10kg weight loss despite an enormous appetite. On the bright side, he has become completely impervious to the cold & the extra money they’ve spent on groceries has been saved on heating bills. Observations are:

A intact

B RR 40, sats 100%, chest clear

C HR 140, BP 180/100, CR 2 sec

D E4(staring & bulging), V4 (agitated & aggressive), M5 (localising to pain), no focal neurology

E Temp 38.5, BSL 10, vomiting, no rash or other signs

a. What is your provisional and differential diagnosis for this man’s clinical picture? (3 marks)

Provisional diagnosis:

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Differential diagnosis:

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JB answer: I’d say they need at least:

• Most likely thyroid storm

• But also other causes of confusion & high temperature e.g.

o Infection (meningoencephalitis, sepsis of any source)

o Too much drug: e.g. salicylates, TCAs, anticholinergics, amphetamine/cocaine,

o Too little drug: e.g. withdrawal of etoh/benzos, heat stroke, phaeochromocytoma)

b. What conditions may precipitate this clinical picture? (2 marks)

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JB answer: I’d say they need to recognise that nasties need to be ruled out, and at least 1 of the other preciptants:

• Nasty precipitants eg acute MI, sepsis, trauma, IV contrast

• UnderDx/Rx TTX esp Graves

• Also XS thyroxine or too little antithyorid Rx

c. How will you treat him in the ED? (5 marks)

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JB answer: I’d suggest they cover everything in bold (not exact doses or details)

• Address ABC/ good supportive care, esp:

o O2 & IV fluids, because high risk of dehydration & cardiovascular collapse

o Sedation eg benzodiazepine

• Get help: from clever endocrinologists, and needs ICU

• Investigations:

o Endocrine blood tests esp TFT

o Seek and treat nasty DDx and nasty precipitants e.g. sepsis, ingestion, MI

d. Specific ED Rx of thyroid storm:

a. IV B-blocker

b. Hydrocortisone 100mg IV

c. Carbimazole load PO/NGT (exact dose I’d look up) then after 4h add Lugols iodine drops)

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