CHF, congestive heart failure; ICU, intensive care unit; T 4, thyroxine; TSH, thyroid-stimu lating hormone. pranolol, radioactive iodine, subtotal thyroidectomy, and

 

treat and admit to ICU

Figure 68-2. Thyroid emergencies diag nostic algorithm.

CHF, congestive heart failure; ICU, intensive care unit; T 4,

thyroxine; TSH, thyroid-stimu lating hormone.

pranolol, radioactive iodine, subtotal thyroidectomy, and

occasionally steroids.

Prompt initiation of supportive treatment for patients

presenting in myxedema coma is very important and

includes IV fluids, passive rewarming, and possibly pressors and mechanical ventilation. TH should be replaced by

IV administration of T4 (levothyroxine) or free T3 (liothyronine or triiodothyronine). In severe myxedema coma,

T 3 should be given, either combined with T 4 or alone

(caution is necessary in patients with myocardial compromise). Administration of IV steroids is routinely recom ­

mended. A baseline cortisol level before initiating steroid

therapy should be obtained.

Uncomplicated hypothyroid patients can be treated

with oral replacement therapy using levothyroxine.

DISPOSITION

� Admission

Admit patients with concomitant illness such as CHF or

dysrhythmia. An ICU setting is indicated for patients with

thyroid storm or myxedema coma.

� Discharge

Discharge patients with uncomplicated thyrotoxicosis or

hypothyroidism, with proper instructions, timely referral,

and the initiation of treatment.

SUGGESTED READING

American Thyroid Association. Professional Guidelines. http:/ I

thyroidguidelines.net/

Idrose AM. Thyroid disorders: Hypothyroidism and myxedema

crisis. In: Tintinalli JE et al., Tintinalli's Emergency Medicine: A

Comprehensive Study Guide. 7th ed. New York, NY: McGrawflill, 201l, pp. 1 444-1447.

Idrose AM. Thyroid disorders: Hyperthyroidism and thyroid

storm. In: Tintinalli JE et al., Tintinalli's Emergency Medicine:

A Comprehensive Study Guide. 7th ed. New York, NY:

McGraw-fUll, 201 1, pp. 1447-1453.

McKeown NJ, Tews MC, et al. Hyperthyroidism. Emerg Med Clin

North Am. 2005;23:669.

Pimentel L, Hansen K. Thyroid disease in the emergency department: A clinical and laboratory review.! Emerg Med. 2005;28:20 1.

Tews MC, Shah SM, et al. Hypothyroidism: Mimicker of com ­

mon complaints. Emerg Med Clin North Am. 2005;23:649.

Adrenal Emergencies

lsam F. Nasr, MD

Key Points

• Adrenal crisis is a medical emergency and must be

recognized and treated promptly.

• Admin istration of steroids, saline, and vasopressors (as

needed) should be instituted when adrenal crisis is

suspected.

INTRODUCTION

Cortisol secretion is regulated by adrenocorticotropic

hormone (ACTH), which, in turn, is regulated by

corticotrophin-releasing hormone (CRH) from the hypothalamus. Aldosterone secretion is regulated by the reninangiotensin system.

Adrenal insufficiency is the failure of the adrenal cortex

to produce adequate amounts of cortisol, aldosterone, or

both. Primary adrenal insufficiency (Addison disease)

refers to failure of the adrenal gland as a result of tissue

destruction, most frequently from an autoimmune process

(70o/o of cases). It is uncommon, affecting 100 per 1 million

persons.