More pressure more problems

High Pressure Injection Injury Occurs when fluid is expelled at least 100 pounds per square inch.  The fluid punctures skin and can dissect up along facial plains, neurovascular bundles, and tendons.   This can easily cause compartment syndrome, deep infections, and debilitating fibrosis.  Extremity necrosis can develop within 12 hours.  Even with expeditious OR debridement and washout there is a 38% risk of amputation and with caustics or higher pressure the risk is up to 80%.  Those that keep their limb lose a great deal of functionality.

Demographic:

• Young adult typically male injured non-dominant hand

• Inexperienced operator of equipment

• exposure material is paint, grease, water, oil, diesel, paint thinner,

Acute phase

• onset within 4-6 hours

• paresthesias, pain, swelling,

• vascular compromise

• compartment syndrome

• injury site may have no skin perforation or small subtle pinhole

ED steps:

1. Recognize this minuscule puncture site is a huge life changing problem

2. Broad spectrum antibiotics

3. Tetanus

4. Hand consultation for OR wash out/debridement

5. X-ray--> lead base paint is radio opaque but may appear like calcifications. Other paints will show sub-cutaneous emphysema. Grease will appear as a lucency.

6. analgesia

7. council patient of detriment to extremity function

Sepsis minus a source? ADDrenal?

Adrenal Crisis Loss of mineralocorticoid and/or glucocorticoid production. Dysfunction is at level of pituitary (secondary or tertiary cause) or the adrenals (primary) with multiple causes:

• autoimmune

• suppression from exogenous hormone use

• hemorrhage

• tumor

• infection

Clinical picture:

• abdominal pain

• vomiting

• diarrhea

• hypotension

• refractory shock

• fever

• confusion

Chronic insufficiency will also give: weight loss, fatigue, arthralgia, myalgia, anorexia, mood change, syncope history, salt cravings, hyper pigmentation, vitiligo

Fever, shock, and confusion sounds like septic shock can labs help?

**for adrenal crisis a random cortisol level below 3 μg/dl (80 mmol/L) is diagnostic but will not be low in all cases

other labs you can expect to find, hypoglycemia, hyponatremia, hyperkalemia, elevated BUN creatinine, hypo-osmolarity

Treatment:

• supportive measures

• stress dose steroid hydrocortisone 100mg IV Q6

Bottom line -in your patients with refractory shock send cortisol level and give stress dose steroid

-consider this diagnosis in patients with autoimmune history, recently postpartum, chronic steroids, Sepsis with no source,

Disposition:

ICU

Cause You're Hot Then You're Cold

Today we will start a miniseries on endocrine emergencies. Myxedema coma -severe hypothyroidism Clinical Features: -Hypothermia -Hypoglycemia -Hypoventilation--> hypoxia, hypercapnia, -Hyponatremia in 50% of patients -Hypotension & bradycardia -Hypomentation, obtunded can conversely have psychosis -Myxedema, nonpitting edema due to deposition mucin & albumin --> can complicate airway -Seizure

Work up: -Work up other pathology -TSH (high) -T4 (low) -T3 (low) -Cortisol (to check for adrenal insufficiency)

Specific treatment: -Initial dose 200-400mcg T4(levothyroxine) IV then daily 50-100mcg IV -Plus initial dose 5-20mcg T3(liothyronine) then 2.5-10mcg every 8 hours,  continue T3 until patient stable -Optimal dose may be moderate dose, use lower doses in older frailer patients -Stress dose steroid hydrocortisone 100 mg every 8 hours

Disposition: ICU

Thyroid storm -too much thyroid, think elevated metabolism and stress response Clinical Features: -Tachycardia--> 60% patients have tachycardia or atrial fibrillation -CHF -Arrhythmia -Cardiac arrest -Hyperpyrexia often 104-106 -Agitation -Psychosis -May be obtunded or comatose -Hand tremor -Diaphoretic -Nausea, diarrhea, and vomiting

Work up: -TSH (low) -T3 (high) -T4 (high) may also have hyperglycemia, mild hypercalcemia, leukocytosis,

Specific treatment: (it is important to give betablocker before inhibiting thyroid hormone synthesis) 1. Propanolol 0.5-1mg IV over 3-5 minutes repeat every 5-10 minutes till heart rate <100 -OR use esmolol, load 250-500mcg/kg, infusion 50-100mcg/kg/min -CHF is high output still give test doses betablocker 2. PTU (propylthiouracil) load 600-1000mg then 300mg every 6 hours give PO, NG, PR (preffered in pregnancy) -OR use methimazole20-30 mg every 6 hours 3. corticosteroid, hydrocortisone 100mg IV every 8 hours -OR use Dexamethazone 2-4mg IV every 6 hours (dexamethazone does not scew cortisol tests) 4. inhibit thyroid production with inorganic iodine -Potassium Iodide: 5 oral drops -OR Lugol's solution 10 oral drops