Endocrine/Metabolic

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.

Pearls

Deep Dive

• Adrenal Crisis in the ED (emDOCs)

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)

Pearls

Deep Dive

• DKA recognition and management (EM Cases)

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)

Pearls

Deep Dive

• Hyperthyroidism ED presentations (emDOCs)

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)

Pearls

Deep Dive

• Thyroid Storm Management (emDOCs)