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

Not a we problem, an eye problem.

Here is a light visual sampling of eye pathology.

Pterygium:  no acute intervention, follow up pmd +/- opthomology, if impinging on pupil patient will require surgical removal of this benign growth.

Teardop pupil: indicates globe rupture and intraocular foreign body until proven otherwise,  protect globe from any external pressure with eye shield, reduce and prevent IOP elevation- elevate head of bed 30 degrees, analgesia, control hypertension, no valsalva maneuvers, prevent vomiting, EMERGENT optho OR

Hordeolum/Chalazion:  no acute intervention, warm packs, no antibiotics indicated, pcp follow up

Hyphema: blood in the anterior chamber can be traumatic or spontaneous only needs urgent ophthalmology follow up if up to the pupil. no ED intervention unless signs of intraocular infection then this is an emergency.

Hypopyon: sign of wide range pathology, can be secondary to trauma, perform woods lamp exam for ulceration, slit lamp exam look for uveitis, urgent opthomology follow up, if infectious etiology suspected systemic antibiotics,

Corneal abrasion: seen on woods lamp exam, raise suspicion for eyelid foreign body be sure to evert both eyelids,  flush eye with saline to remove small foreign body, if abrasion is overlying the pupil antibiotic and urgent ophthalmology follow up.  patient should not wear contacts on injured eye until healed

Dedritic ulceration:  Herpetic keratitis treat with po acyclovir or opthalmic antiviral, Urgent opthalmology follow up.

Corneal ulceration: ensure no sign perforation-seidel sign,  opthalmic antibiotics, urgent optho follow up, if patient wears contacts add coverage for Pseudomonas,  do not wear contacts until healed.

Seidel sign: vitreous flowing from site of globe perforation, emergent optho consult in the ER.  protect globe from any external pressure with eye shield, reduce and prevent IOP elevation- elevate head of bed 30 degrees, analgesia, control hypertension, no valsalva maneuvers, prevent vomiting,

Exopthalmos: if in setting of trauma with increased intraocular pressure perform lateral canthotomy,   suspect retrobulbar hematoma or orbital cellulitis,  CT scan emergent optho consult,

Corneal foreign body with rust ring: remove foerign body, urgent follow up for rust ring removal which should be done after 24 hours from initial injury, this is because reepithelialization makes removal easier.