1. Endocrine
EmergenciesWayne Triner, DO, MPH
Emergency Medicine

2. A 24 year old female presents with three days of progressive
alteration of mental status. Today she was found by her partner to
be highly anxious and seemingly with paranoid delusions. There is
a history or prior alcohol use. She has not been at work as an artist
(potter) for the past 4 days.
PMHx: RA, Asthma
Exam:
Agitated, diaphoretic, shifting in bed, Unintelligible speech.
402, 136, 40, 132/68
HEENT, Neck, Lungs: normal
Heart: tachy, regular, 2/6 systolic ejection murmur
Abd: silent, non-distended, non-tender
Neuro: mental status as described, non-focal, fine tremor
Ext: no edema, no marks, no hot joints
Derm: pink, moist, no rash
A 42 year old female presents with three days of progressive
alteration of mental status characterized as somnolence and
intermittent anxiety. There is a history of prior alcohol use. She has
not been at work as an artist (potter) for the past 4 days.
PMHx: RA, Asthma
Exam:
Agitated, shifting in bed, Unintelligible speech.
342, 52, 40, 106/70
HEENT, Neck, Lungs: normal
Heart: tachy, regular, 2/6 systolic ejection murmur
Abd: silent, non-distended, non-tender
Neuro: mental status as described, non-focal
Ext: “brawny” edema on legs, no marks, no hot joints
Derm: pink, moist, no rash
A 46 year old female presents with three days of progressive
alteration of mental status characterized as somnolence and
intermittent anxiety. There is a history of prior alcohol use. She has
not been at work as an artist (potter) for the past 4 days.
PMHx: RA, Asthma
Exam:
Agitated, shifting in bed, Unintelligible speech.
342, 52, 40, 106/70
HEENT, Neck, Lungs: normal
Heart: slow, regular, 2/6 systolic ejection murmur
Abd: silent, non-distended, non-tender
Neuro: mental status as described, non-focal
Ext: no edema, no marks, no hot joints
Derm: pink, moist, no rash
A 24 year old male presents with three hours of progressive alteration
of mental status characterized as highly aggitated. There is a history
of prior alcohol and illicit substance use. He was encountered by
police and “Tazer’d”. He is restrained, face-down on the ambulance
gurney.
PMHx: RA, Asthma
Exam:
Agitated, diaphoretic, shifting in bed, Unintelligible speech.
402, 184, 40, 236/130
HEENT, Neck, Lungs: normal
Heart: tachy, regular, 2/6 systolic ejection murmur
Abd: silent, non-distended, non-tender
Neuro: mental status as described, onset of seizure upon arrival
Ext: no edema, no marks, no hot joints
Derm: pink, moist, no rash

3. Anxious, Delirious,
Altered
Hyperadrenergic /
Hypermetabolic State
Elevated blood pressure
Tachycardia
Delerium
Hyperpyrexia
Causes
• Intoxication
• Psychosis
• Endocrine
Excited Delirium

4. Hyperthyroidism
Suppressed TSH
Normal T4
Suppressed TSH
Elevated T4
Subtle Symptoms
Suppressed TSH
Elevated T4
Dominant
Symptoms
Suppressed TSH
Elevated T4
Severe Symptoms
Altered Mental Status

5. Thyroid Storm (crisis)
• Dx: Hyperthyroid with altered mental status
• Generally with hyperpyrexia
• Most common in 20’s and 30’s
• 4:1 female to male
• Incidence unknown
• However, thyrotoxicosis may effect 2% of women
• Small percentage of whom experience Thyroid Storm
• Many Causes
• Precipitated by;
Sepsis Thyroid trauma
Exogenous TH Iodine exposure
“Hot nodule” Protein displacement (ASA, furosamide, NSAIDs)
Surgery

6. Important Findings
Thyrotoxicosis
Symptoms Signs
NeuroPsych Anxiety
Nervousness / Agitation
Coma
Tremor
Periodic paralysis
Muscle wasting
Hyperreflexia
Endocrine Oligomennorhea
Decreased libido
Gynecomastia
GI Hypermotility
CardioVasc Palpitations
Chest pain
Dyspnea
S. Tach (40%)
A Fib (20%)
High output failure
Derm Hair loss Moist skin
Pre-tibial myxedema

7. Laboratory and Imaging
• Increased T4 / Decreased TSH
• Increased Free T3 / T4 ratio
• Likely of thyroid origin
• Hyperglycemia
• Adrenocortical dysfunction
• Increased production
• Increased metabolism
• Reduced adrenal response to
ACTH Stim test
• Thyroid ultrasound
• Increased vascularity
• Nodules
• Normal

8. Thyroglobulin
Synthesis
Iodination &
Conjugation
Proteolysis to T3 & T4
Secretion
Peripheral Conversion of T4
to T3
Cellular Effect

9. Thyrotoxicosis/Storm
Treatment
• Supportive care
• Controlling adrenergic effects
• Stop synthesis of new T4 & T3
• Stop release of stored T4 & T3
• Preventing peripheral
conversion of T4 to T3
• Ventilatory support
• Thermoregulation
• Hemodynamic support
• Identify and treat
underlying cause
• Propranolol (β1 & β2)
ONLY 1 Hr.
FOLLOWING PTU
• Iodine
• SSKI
• Lugol’s soln
• PTU
• Hydrocoritsone
PTU
• Short duration of
action
• Hepatotoxic
• Prevents conversion
of T4 to T3
Methimizole
• Does not impact T4
to T3 conversion

10. Thyrotoxicosis/Storm
Treatment
1. β-Blocker
• Propanolol
• Esmolol
2. PTU or methimizole
3. Hydrocortisone
4. Iodine*
• SSKI
• Lugol’s Solution
5. Generally, definitive control of hyperthyroidism isn’t
considered until thyrotoxicosis/storm is controlled for at least
six weeks.

11. A 24 year old female presents with three days of progressive
alteration of mental status. Today she was found by her partner to
be highly anxious and seemingly with paranoid delusions. There is
a history or prior alcohol use. She has not been at work as an artist
(potter) for the past 4 days.
PMHx: RA, Asthma
Exam:
Agitated, diaphoretic, shifting in bed, Unintelligible speech.
402, 136, 40, 132/68
HEENT, Neck, Lungs: normal
Heart: tachy, regular, 2/6 systolic ejection murmur
Abd: silent, non-distended, non-tender
Neuro: mental status as described, non-focal, fine tremor
Ext: no edema, no marks, no hot joints
Derm: pink, moist, no rash
A 42 year old female presents with three days of progressive
alteration of mental status characterized as somnolence and
intermittent anxiety. There is a history of prior alcohol use. She has
not been at work as an artist (potter) for the past 4 days.
PMHx: RA, Asthma
Exam:
Agitated, shifting in bed, Unintelligible speech.
342, 52, 40, 106/70
HEENT, Neck, Lungs: normal
Heart: tachy, regular, 2/6 systolic ejection murmur
Abd: silent, non-distended, non-tender
Neuro: mental status as described, non-focal
Ext: “brawny” edema on legs, no marks, no hot joints
Derm: pink, moist, no rash
A 46 year old female presents with three days of progressive
alteration of mental status characterized as somnolence and
intermittent anxiety. There is a history of prior alcohol use. She has
not been at work as an artist (potter) for the past 4 days.
PMHx: RA, Asthma
Exam:
Agitated, shifting in bed, Unintelligible speech.
342, 52, 40, 106/70
HEENT, Neck, Lungs: normal
Heart: slow, regular, 2/6 systolic ejection murmur
Abd: silent, non-distended, non-tender
Neuro: mental status as described, non-focal
Ext: no edema, no marks, no hot joints
Derm: pink, moist, no rash
A 24 year old male presents with three hours of progressive alteration
of mental status characterized as highly aggitated. There is a history
of prior alcohol and illicit substance use. He was encountered by
police and “Tazer’d”. He is restrained, face-down on the ambulance
gurney.
PMHx: RA, Asthma
Exam: Agitated, diaphoretic, shifting in bed, Unintelligible speech.
402, 184, 40, 236/130
HEENT, Neck, Lungs: normal
Heart: tachy, regular, 2/6 systolic ejection murmur
Abd: silent, non-distended, non-tender
Neuro: mental status as described, onset of seizure upon arrival
Ext: no edema, no marks, no hot joints
Derm: pink, moist, no rash

12. Excited Delirium
Fatal Cases
• 95% male
• Mean age 36
• Almost all engage law
enforcement
• Resisted struggle
• TASER use
• Restraint
Commonalities
• Face-down restrain
• Period of “giving-up”
• Inability to resuscitate
• Basil ganglion lack of
dopamine
(exhaustion hypothesis)

13. ExDS Management
• Restrain supine
• Benzodiazepines
• Constant, direct observational monitoring
• Control hyperthermia
• Anticipate acidosis

14. A 24 year old female presents with three days of progressive
alteration of mental status. Today she was found by her partner to
be highly anxious and seemingly with paranoid delusions. There is
a history or prior alcohol use. She has not been at work as an artist
(potter) for the past 4 days.
PMHx: RA, Asthma
Exam:
Agitated, diaphoretic, shifting in bed, Unintelligible speech.
402, 136, 40, 132/68
HEENT, Neck, Lungs: normal
Heart: tachy, regular, 2/6 systolic ejection murmur
Abd: silent, non-distended, non-tender
Neuro: mental status as described, non-focal, fine tremor
Ext: no edema, no marks, no hot joints
Derm: pink, moist, no rash
A 64 year old female presents with three days of progressive
alteration of mental status characterized as somnolence and
intermittent anxiety. There is a history of prior alcohol use. She has
not been at work as an artist (potter) for the past 4 days.
PMHx: RA, Asthma
Exam:
Agitated, shifting in bed, Unintelligible speech.
342, 42, 10, 106/70, SpO2 .86
HEENT, Neck, Lungs: normal
Lungs: bi-basilar crackles
Heart: slow, regular, 2/6 systolic ejection murmur
Abd: silent, distended, non-tender
Neuro: mental status as described, non-focal
Ext: “brawny” edema on legs, no marks, no hot joints, dry skin
A 46 year old female presents with three days of progressive
alteration of mental status characterized as somnolence and
intermittent anxiety. There is a history of prior alcohol use. She has
not been at work as an artist (potter) for the past 4 days.
PMHx: RA, Asthma
Exam:
Agitated, shifting in bed, Unintelligible speech.
342, 52, 40, 106/70
HEENT, Neck, Lungs: normal
Heart: slow, regular, 2/6 systolic ejection murmur
Abd: silent, non-distended, non-tender
Neuro: mental status as described, non-focal
Ext: no edema, no marks, no hot joints
Derm: pink, moist, no rash
A 24 year old male presents with three hours of progressive alteration
of mental status characterized as highly aggitated. There is a history
of prior alcohol and illicit substance use. He was encountered by
police and “Tazer’d”. He is restrained, face-down on the ambulance
gurney.
PMHx: RA, Asthma
Exam:
Agitated, diaphoretic, shifting in bed, Unintelligible speech.
402, 184, 40, 236/130
HEENT, Neck, Lungs: normal
Heart: tachy, regular, 2/6 systolic ejection murmur
Abd: silent, non-distended, non-tender
Neuro: mental status as described, onset of seizure upon arrival
Ext: no edema, no marks, no hot joints
Derm: pink, moist, no rash

15. Na 122
K 4.3
NaHCO3 36
Hgb 105
Labs and Findings

16. Hypothyroidism
• General reflection of organ system slowing
• Accumulation of glycosaminoglycans
• Derm changes
• Many underlying causes
• Autoimmune
Graves
Hashimoto’s
• Iatrogenic
• Primary / Secondary
None of this matters to us

17. Hypothyroidism
Elevated* TSH
Normal T4
Elevated* TSH
Reduced T4
+Symptoms
Elevated* TSH
Reduced T4
Severe Symptoms
40% Mortality

18. Myxedema Coma
Case Definition
Severe hypothyroidism
• Alteration of mental
status
• Hypothermia
• Bradycardia
Diagnostic Clues
• Thyroid ablation or
thyroidectomy
• Often insidious
Slow progressive
reduced mental
status
• Hypothermia
• Hypoventilation
• Hyponatremia
• Hypo…

19. Myxedema Coma
Treatment
• Consider the Diagnosis
TSH & T4
• Supportive
• Thermoregulation
• Ventilation
• Empirically treat adrenal
insufficiency
Spot cortisol level
• Seek and treat SEPSIS
• Avoid over resuscitation
• Specific
Thyroid Replacement
T4 “physiologic”
conversion to T3
T3 rapid onset of action
T4 & T3

20. A 24 year old female presents with three days of progressive
alteration of mental status. Today she was found by her partner to
be highly anxious and seemingly with paranoid delusions. There is
a history or prior alcohol use. She has not been at work as an artist
(potter) for the past 4 days.
PMHx: RA, Asthma
Exam:
Agitated, diaphoretic, shifting in bed, Unintelligible speech.
402, 136, 40, 132/68
HEENT, Neck, Lungs: normal
Heart: tachy, regular, 2/6 systolic ejection murmur
Abd: silent, non-distended, non-tender
Neuro: mental status as described, non-focal, fine tremor
Ext: no edema, no marks, no hot joints
Derm: pink, moist, no rash
A 64 year old female presents with three days of progressive
alteration of mental status characterized as somnolence and
intermittent anxiety. There is a history of prior alcohol use. She has
not been at work as an artist (potter) for the past 4 days.
PMHx: RA, Asthma
Exam:
Agitated, shifting in bed, Unintelligible speech.
342, 42, 10, 106/70, SpO2 .86
HEENT, Neck, Lungs: normal
Lungs: bi-basilar crackles
Heart: slow, regular, 2/6 systolic ejection murmur
Abd: silent, distended, non-tender
Neuro: mental status as described, non-focal
Ext: “brawny” edema on legs, no marks, no hot joints, dry skin
A 46 year old female presents with three days of progressive
alteration of mental status characterized as somnolence and
intermittent anxiety. She has been vomiting and expressing
abdominal pain for 24 hours. There is a history of prior alcohol use.
She has not been at work as an artist (potter) for the past 4 days.
PMHx: Asthma Meds unknown
Exam: Agitated, shifting in bed, Unintelligible speech.
382, 136, 40, 86/70
HEENT, Neck, Lungs: normal
Heart: slow, regular, 2/6 systolic ejection murmur
Abd: silent, non-distended, diffusely tender
Neuro: mental status as described, non-focal
Ext: no edema, no marks, no hot joints
Derm: pink, moist, no rash
A 24 year old male presents with three hours of progressive alteration
of mental status characterized as highly aggitated. There is a history
of prior alcohol and illicit substance use. He was encountered by
police and “Tazer’d”. He is restrained, face-down on the ambulance
gurney.
PMHx: RA, Asthma
Exam:
Agitated, diaphoretic, shifting in bed, Unintelligible speech.
402, 184, 40, 236/130
HEENT, Neck, Lungs: normal
Heart: tachy, regular, 2/6 systolic ejection murmur
Abd: silent, non-distended, non-tender
Neuro: mental status as described, onset of seizure upon arrival
Ext: no edema, no marks, no hot joints
Derm: pink, moist, no rash
Her partner arrives and reports that
she is a fragile asthmatic and has been
to several EDs over the course of the
past year. She has been on Prednesone
almost continuously for 10 months.

21. Adrenal Crisis
• Widely variable presentation
• Largely dependent upon etiologies
• Primary, secondary, tertiary
• Wide range of etiologies
• Precipitating event

22. Diagnostic Clues
Findings
• Physical Exam
• Laboratory
• Hyponatremia 85%
• Neuro-psych
The Traps
• Surgical referral for abd
pain and fever
• Failure to recognize
• Failure to carry out
diagnostic tests

23. Approach to
Management
• Fluid resuscitation
• Treat empirically with
dexamethasone
• Seek provoking cause
• Short ACTH stim test
1. Baseline serum cortisol
2. Co-syntropin® 250 mcg IV
3. 30 and 60 minute serum
cortisol
• Normal outocome
• 18-20 mcg/dl (500 nmol/L)

24. Endocrine
EmergenciesWayne Triner, DO, MPH
Emergency Medicine