hhnk thyroid disorders dr. miada mahmoud rady ems /474
TRANSCRIPT
HHNKTHYROID DISORDERS
Dr. Miada Mahmoud Rady
EMS /474
HHNK
HHNK
HHNK : Hyperosmolar Hyperglycemic Non Ketotic
Syndrome.
Also known as ; HONK : Hyperosmolar Non Ketotic
Syndrome.
It is life threatening complication of hyperglycemia .
Commonly seen in elderly type 2 diabetics .
Develops slowly over days .
Pathophysiology
Hallmark of HHNK is marked Hyperglycemia , patient RBG is
usually more than 600mg/dl .
Marked hyperglycemia caused Increased Blood Osmolarity
which causes Osmotic Diuresis (polyuria).
Marked polyuria causes Sever Dehydration And Electrolyte
Imbalance (most prominently Hypernatremia ).
Hyperglycemia in HHNK can be either due to insulin deficiency
due to increased requirement or inappropriate action due to
increased counter regulatory hormones.
Pathophysiology
Patient with HHNK has no or very minimal ketosis……???
Because the amount of insulin present however small is
sufficient to prevent fatty acid metabolism but not sufficient to
prevent hyperglycemia .
Predisposing factors
1. Missed insulin .
2. Heavy meal .
3. Acute pancreatitis.
4. Infection .
5. Trauma .
6. Surgery .
7. MI .
8. Pregnancy.
Decreased insulin reserve
Increased insulin requirement
Clinical Tip
• For HHNK to occur the patient should be unable to
compensate marked water loss caused by hyperglycemia to
produce hyperosmolarity (which is major criteria of HHNK)
i.e. the should be unable to drink
• That is why HHNK is common in elderly ( they have an
impaired thirst sensation , unable to serve them selves ) , and
in young it is seen if the patient ability to reach water is
impaired as by intubation , anesthesia , NPO protocol .
Criteria of HHNK
1. Hyperglycemia ( marked dehydration ).
2. Hyperosmolarity ( increased serum osmolarity i.e. sodium
concentration ).
3. Marked dehydration.
4. Absent or very minimal ketosis.
5. No acidosis.
Clinical Presentation of HHNK
1.Slow progression of symptoms over days.
2.Dehydration( warm flushed skin , dry tongue , and mucous
membranes)
3.Polyuria followed by Oliguria late.
4.Prominent neurological features as :
Drowsiness
Focal or generalized seizures
Hemiparesis and Sensory deficits
Patient slowly passes into coma.
Laboratory Finding
1. Hyperglycemia : more 600mg/dl.
2. Hypernatremia : increased serum sodium.
3. No or very minimal ketosis.
4. No ketonuria .
Management
Follow the general guidelines for patient care :
1. Airway :
Top priority
Manage and maintain patent airway as indicated
If the patient is comatosed protect airway , be ware of vomiting
and have suction ready .
Advanced airway and ETT may be needed
2. Breathing :
Maintain adequate oxygenation.
3. Circulation :
Record and continuously monitor cardiac rhythm and
vital signs.
Obtain serial 12 lead ECG .
Measure blood glucose level .
Start an I.V line and Give 12.5 – 25 gm of 50% dextrose
if blood glucose level is below 70 mg/dl or cannot be
determined.
Management
Management
Start normal saline per local protocols :
1. Give 500 ml normal saline over 30 minutes as bolus.
2. In patients with a history of congestive heart failure
and/or renal insufficiency, a 250-mL bolus may be more
appropriate.
3. Patients may receive 1 to 2 L within the first hour.
Management
3. Transport patient rapidly .
4. Continuously reassess patient (A,B and C).
MMR
ThyroidGland
disorders
Thyroid Control
• Thyroid gland secretes thyroid hormone in response to
stimulation from anterior pituitary by thyroid stimulating
hormone ( TSH ) , which is released in response to stimulation
of anterior pituitary by thyroid releasing (TRH) by
hypothalamus .
• Thyroid hormones in turn inhibit the anterior pituitary
secretion of TSH and hypothalamus secretion of TRH.
Hypothalamo-pituitary Thyroid
Axis.
Thyroid gland disorders
Result from either Increased or decreased thyroid
hormone production:
1. Increased thyroid hormone production is called
hyperthyroidism.
2. Decreased thyroid hormone production is called
hypothyroidism.
Hyperthyroidism and Thyrotoxicosis
Hyperthyroidism : increased level of circulating thyroid
hormone ,( laboratory finding).
Thyrotoxicosis : toxic syndrome resulting from increased
level of circulating thyroid hormone , (clinical term ).
Myxoedema: clinical syndrome resulting from decreased
level of circulating thyroid hormone below normal.
Clinical Presentation of Thyrotoxicosis
1. Irritability , nervousness.
2. Insomnia .
3. Weight loss.
4. Excessive sweating .
5. Intolerance to hot weather.
6. Tachycardia .
7. Thyrotoxic heart failure.
8. Dyspnea .
9. Diarrhea .
10. Menstrual irregularities .
11. Hand tremers.
Special Types of Hyperthyroidism
1. Graves disease :
Most common form of hyperthyroidism.
More common females .
Autoimmune disorder .
It is sever and may be fatal if untreated.
In addition to the common symptoms of Thyrotoxicosis , it
has 3 characteristic finding:
Graves disease
1. Exophthalmos : forward protrusion of the rye
ball .
2. Pretibial Myxoedema : non pitting edema of
the skin on the anterior part of the leg below the
knee.
3. Goiter : diffuse enlargement of the thyroid
gland.
Exophthalmos and goiter
Exophthalmos and goiter
Hashimoto disease
More common in females .
It is an autoimmune disorder caused by production of auto
antibodies against TSH receptors on thyroid follicles causing
first over hyperthyroidism and Thyrotoxicosis , followed by
destruction of TSH receptors causing hypothyroidism .
So the patient first present with Thyrotoxicosis followed by
hypothyroidism.
Clinical Presentation Hypothyroidism
1. Slow cerebration and depression .
2. Excessive sleeping .
3. Weight gain.
4. Intolerance to cold weather .
5. Dry skin.
6. Bradycardia .
7. Hypertension and IHD.
8. Menstrual irregularities .
9. Constipation .
THYROID EMERGENCIES
Thyroid Storm
Definition : rare life threatening exacerbation of manifestation
of thyrotoxicosis .
Predisposing factors :
1. Stress .
2. Operation.
3. Trauma .
4. Infection.
Clinical presentation
1. High grade fever (hyperpyrexia).
2. Severe tachycardia , arrhythmias and heart failure .
3. Nausea .
4. Vomiting .
5. Dehydration.
6. Convulsions , hallucinations and altered mental status.
Management of Thyroid Storm
Mainly supportive care :
1. Ensure patent air way .
2. Maintain adequate oxygenation and ventilation.
3. Continuously assess vital signs .
4. Lower body temperature by cold fomentation , cooling.
5. Phenobarbital is given for convulsion.
6. Rapid transport.
Myxoedema Coma
Definition : rare life threatening complication of untreated
hypothyroidism accompanied by physiological decomposition.
It is seen in long standing untreated cases of hypothyroidism.
More common in elderly females especially during winter.
If not diagnosed and treated immediately, the mortality rates are
approximately 50%.
Predisposing factors
1. Infection (especially pulmonary and urinary tract).
2. Exposure to cold.
3. Trauma.
4. Surgery.
5. Certain medications e.g. those used to treat advanced cases of
diabetic neuropathy pregablin .
Clinical presentation
1. Hallmark is Deterioration Of Mental Status ( old , obese
female who become lethargic , sleepy and easily slips to
coma).
2. Hypothermia even in presence of infection.
3. Hypoventilation and hypoxia.
4. Symptoms of hypothyroidism .
Management
1. Airway and breathing :
a. Administer supplemental oxygen therapy to
correct hypoxia.
b. Intubation and ventilation may be indicated.
2. Circulation :
a. Continuously monitor the patient’s cardiac
rhythm and blood pressure.
b. In case of hypotension crystalloids are
given .
c. Persistent hypotension vasopressors are
given.
d. Administer 25 to 50 g of D50 if glucose
levels are less than 60 mg/dL.
3. Hypothermia treatment :
First try passive rewarming.
Active rewarming is done for hemodynamically
unstable patients with profound hypothermia.
Avoid aggressive rewarming may lead to
vasodilatation and hypotension.
4. Rapidly transport the patient .
Any questions?