Adrenal and Thyroid

Both are “Double Asks” – pt comes in with different apparent condition and this condition lurking in background

  • Sepsis
  • MI
  • GIB
  • Hyponatremia
  • Pregnancy – B-HCG has TSH effects

And are clinical diagnoses that need to be made without confirmatory lab data

Thyroid

When to think of getting TSH/free T3/4

  • On lithium/amiodarone
  • CHF
  • Pregnancy
  • Hyponatremia – don’t metabolize ADH in hypothyroid state

Thyroid Storm

– Burch and Warthofshy’s Calculator to score

  • DDX: Grave’s, toxic multinodular, toxic adenoma, drugs

Management:

BB Blockade – One of the following for goal HR=100 bpm

  • Esmolol 250-500 mcg/kg load then 50-300 mcg/kg/min
  • Propranolol – 1 mg IV test; then 1-2 mg IV q15 min until HR=100 bpm
    • Then start gtt at whatever load dose was required (max 3-5 mg/hr)

or

  • Reserpine 2.5-5 mg preceeded by 5 mg test dose in alert and not chf/hypotensive
  • Cuanethidine PO 30-40 mg if alert and not chf/hypotensive
  • ACEI/diuretic/digoxin
  • NO CCB (bad outcomes in case studies)

Reducing production – One of the following:

  • PTU 600-1000 mg load PO/PR (2.5-3.3 mg/kg) then 250 mg q4h – preferred in pregnancy and may also block peripheral conversion
  • Methimazole 40 mg PO (1.3-2.3 mg/kg) – preferred in neonates
  • Lithium – 300 mg PO (5 mg/kg) – Should probably talk to endocrine 1st

Inhibiting release (60 min later) – One of:

  • Lugol solution 8-10 drops PO (2 drops/10 kg) q6h
  • SSKI – 5 drops PO (1 drop/10 kg) q6h
  • Sodium iodide 500 mg IV q12h
  • Lithiium 300 mg PO (5 mg/kg) – use in case of iodine excess caused disease (e.g. amiodarone induced thyrotoxicosis)

Block peripheral conversion – One of:

  • Dexamethasone 4 mg IV q 6h
  • Hydrocortisone 300 mg IV then 100 mg q8h

Other:

  • Treat volume loss – large insensible losses even in high output failure
  • Avoid aggressive cooling – causes vasoconstriction and inc. afterload
  • Fever control – APAP NOT ibuprofen
  • Anxiolysis – benzodiazepine
  • Block cellular cellular entry – L carnitine 1 g PO (25 mg/kg)
  • Consider plasmapheresis, exchange or dialysis

No deviation from normal management in pregnancy

For subacute thyroiditis, post-partum thyroiditis or thyroxine overdose – DO NOT give production blockade or inhibit release – Gland is healthy, just need BB and block peripheral conversion

Agranulocytosis is a known complication of PTU – Presents w/ sore throat and fever, needs to be distinguished from suppurative thyroiditis (clinda + zosyn), should be switched to lithium for the PTU

Hypothyroid

  • Dex 4 mg IV (0.15-0.3 mg/kg
  • T4 300-500 mcg IV (4 mcg/kg) – extremes of age
  • T4 200-250 IV and T3 10 mcg IV – healthy young people

If treating hyponatremia empirically for hypothyroid need to premedicate w/ Dexamethasone for coincident adrenal insufficiency and also sent ACTH/Cortisol

Adrenal

When to get paired ACTH/Cortisol

  • Weakness
  • Recalcitrant vomiting
  • H/o steroid use last 6-12 mo
  • HIV and critical illness
  • Ambiguous genitalia
  • Hyponatremia
  • When giving decadron for presumed adrenal insufficiency

Adrenal Insufficiency Treatment

  • Hydrocortisone 50-100 mg IV (1 mg/kg)

or

  • Decadron 4 mg IV (0.15/0.3 mg/kg) – doesn’t screw up stim test upstairs

Random cortisol level

  • If sick and < 15 presumed hypooadrenalism
  • Should be treated if b/t 15-33

Send 17-OH progesterone in babies if you’re thinking CAH

Avoid etomidate when intubating for adrenal problems

Don’t need to taper steroid courses of < 3 wks duration