Endocrine/Metabolic

Addison Disease

Rapid Review

  • Background
    • Addison disease is an insidious, usually progressive hypofunctioning of the adrenal cortex causing a deficiency in cortisol and aldosterone.
  • Signs/Symptoms
    • Abdominal pain, N/V, fever, confusion. May present with hyperpigmentation of skin/mucous membranes and hypotension. 
  • Diagnosis
    • Clinical diagnosis; BMP will show hyponatremia, hypoglycemia, and hyperkalemia. Plasma cortisol and aldosterone levels will be low. ACTH (cosyntropin) stimulation test helps confirm diagnosis.
  • Treatment
    • Hydrocortisone, supportive care.
  • Disposition
    • New or acute presentations of adrenal insufficiency should be admitted (floor or ICU depending on severity)
    • Patients with established chronic insufficiency can be discharged with endocrinology if stable and no significant electrolyte abnormalities.

Pearls

  • Acute adrenal insufficency can be a life-threatening presentation. If suspicious for it, do not delay treatment with steroids while awaiting for lab results.
  • Hydrocortisone is the steroid of choice given it’s combination of glucocorticoid and mineralcorticoid effects, but may interfere with cosyntropin testing. Dexamethasone is a second line option that will not interfere with this test. 
Video Credit: AETCM Emergency Medicine

Adrenal Crisis

Rapid Review

Pearls

Deep Dive

Diabetic Ketoacidosis

Rapid Review

  • Background
    • Diabetic ketoacidosis is caused by a relative lack of insulin in patients with type 1 diabetes who lack insulin production, typically in the setting of an acute illness or missed insulin dosing. 
  • Signs/Symptoms
    • Abdominal pain, nausea/vomiting, fatigue, altered mental status.
    • May be dehydrated, tachycardic, and have a fruity-smelling breath.
  • Diagnosis
    • Diagnosis requires anion gap metabolic acidosis (pH < 7.3), ketonemia (elevated beta-hydroxybutyrate), and hyperglycemia (glucose > 250 mg/dL)
    • Patients on SGLT2-inhibitors may be euglycemic
  • Treatment
    • IV fluids, insulin infusion, and electrolyte repletion (especially potassium)
  • Disposition
    • Most patients will require admission (placement depends on acuity). Severe cases must go to ICU.
    • Stable patients with resolution of DKA can be discharged with close follow-up with endocrinologist or PCP.

Pearls

  • Insulin causes potassium to shift intracellulary, which can cause hypokalemia. Avoid giving insulin unless serum potassium is at least > 3.3 mEq/L
  • Cerebral edema is a rare, but deadly complication of DKA, especially in children. Do not be overly aggressive with fluid resuscitation. 
Video Credit: Armando Hasudungan

Hyperosmolar Coma

Rapid Review

Pearls

Deep Dive

Hypoglycemia

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Pearls

Deep Dive

Hypokalemia

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Pearls

Deep Dive

Hyperkalemia

Rapid Review

Pearls

Deep Dive

Hypomagnesemia

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Pearls

Deep Dive

Hypermagnesemia

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Pearls

Deep Dive

Hyponatremia

Rapid Review

Pearls

Deep Dive

Hypernatremia

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Pearls

Deep Dive

Hypocalcemia

Rapid Review

Pearls

Deep Dive

Hypercalcemia

Rapid Review

Pearls

Deep Dive

Hypothryoidism

Rapid Review

Pearls

Deep Dive

Hyperthyroidism

Rapid Review

  • Background
    • Hyperthyroidism refers to an increase in the production and release of the thyroid hormone thyroxine. Most commonly caused by Grave’s disease
  • Signs/Symptoms
    • Palpitations, sweating, heat intolerance, and high blood pressure. 
    • Goiter, exophthalmos, pretibial edema
  • Diagnosis
    • Low TSH, Elevated T4 and T3
  • Treatment
    • No treatment in ED required if symptoms are mild
    • If suspect thyroid storm, treat with “ABCWI” (antithyroid durg, beta-blocker, corticosteroids, wait 1 hour, iodine)
  • Disposition
    • Asymptomatic or mild cases can be safely discharged with PCP follow up and endocrinology referral.
    • Admit if signs/symptoms of thyroid storm.

Pearls

  • Both methimazole and propylthiouracil are equally effective for hyperthyroidism, though methimazole is not recommended for first trimester pregnancy.
  • Certain medications, such as amiodarone and lithium, can precipitate hyperthyroidism as well. 
Video Credit: Zero To Finals

Hypoparathyroidism

Rapid Review

Pearls

Deep Dive

Myxedema Coma

Rapid Review

Pearls

Deep Dive

Thyroid Storm

Rapid Review

  • Background
    • Thyroid storm is caused by an acute increase in the production and release of the thyroid hormone thyroxine 
    • Typically precipitated by acute event (surgery,infection, trauma) 
  • Signs/symptoms
    • Confusion, tachycardia, sweating, and high blood pressure. 
    • Goiter, tremors, lid lag
  • Diagnosis
    • Decreased TSH, Elevated T3/T4
  • Treatment
    • Treat with “ABCWI” (antithyroid drug, beta-blocker, corticosteroids, wait 1 hour, iodine)
  • Disposition
    • Admission with continuous cardiac monitoring. Most cases of thyroid storm will require ICU care.

Pearls

  • Remember to block hormone synthesis with methimazole or PTU prior to giving iodine. This will prevent the Jod-Basedow effect (worsening hyperthyroidism following iodine administration)
  • Thyroid storm carries a high mortality (as high a 80-100% without treatment). If suspicious for it, do not delay treatment for confirmatory lab testing. 
Video Credit: EM in 5