Endocrine/Metabolic

  • Addison’s Disease
  • Diabetic Ketoacidosis
  • Hyperthyroidism
  • Thyroid Storm

Addison’s Disease

  • 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.
Video Credit: AETCM Emergency Medicine

*Deep Dive: Adrenal Crisis in the ED (emDOCs)



Diabetic Ketoacidosis

  • 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)
Video Credit: Armando Hasudungan

*Deep Dive: DKA recognition and management (EM Cases)



Hyperthyroidism

  • 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)
Video Credit: Zero To Finals

*Deep Dive: Hyperthyroidism ED presentations (emDOCs)



Thyroid Storm

  • 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)
Video Credit: EM in 5

*Deep Dive: Thyroid Storm Management (emDOCs)


Brandon Simpson, PA-C
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