TREATMENT OF TREATMENT OF ENDOCRINE EMERGENCIESENDOCRINE EMERGENCIES

Sakharova Inna. Ye., M.D, Ph.DSakharova Inna. Ye., M.D, Ph.D

• Endocrine emergencies represent a Endocrine emergencies represent a group of potentially life-threatening group of potentially life-threatening conditions that are frequently conditions that are frequently overlooked, resulting in delays in overlooked, resulting in delays in both diagnosis and treatment, factors both diagnosis and treatment, factors that further contribute to their that further contribute to their already high associated mortality already high associated mortality rates.rates.

The treatment of thyroid stormThe treatment of thyroid storm

• Propylthiouracil (PTU)Propylthiouracil (PTU) blocks blocks peripheral conversion of T4 to T3 and peripheral conversion of T4 to T3 and can be given as a 600- to 1000-mg can be given as a 600- to 1000-mg loading dose, followed by 1200 loading dose, followed by 1200 mg/day divided into doses given every mg/day divided into doses given every 4 to 6 hours.4 to 6 hours.

• MethimazoleMethimazole can be used as an can be used as an alternate agent but does not block alternate agent but does not block peripheral T4 conversion. peripheral T4 conversion.

• Both medications can be administered Both medications can be administered orally, through nasogastric sonde or orally, through nasogastric sonde or rectally if necessary.rectally if necessary.

Peripheral thyroid hormone action Peripheral thyroid hormone action as well as tachycardia and as well as tachycardia and

hypertension can be minimized byhypertension can be minimized by

• beta-blockers: typically beta-blockers: typically propranolol propranolol administered intravenously initially in administered intravenously initially in 1-mg dose every 10 to 15 minutes 1-mg dose every 10 to 15 minutes until symptoms are controlled or until symptoms are controlled or esmolol esmolol administered as a loading administered as a loading dose of 250-500 mcg/kg followed by dose of 250-500 mcg/kg followed by an infusion of 50-100 mcg/kg/minute.an infusion of 50-100 mcg/kg/minute.

• Glucocorticoids: Glucocorticoids: prednisoneprednisone 2-6 2-6 mg/kg mg/kg hydrocortisonehydrocortisone 20 mg/kg 20 mg/kg intravenously every 8 hours with intravenously every 8 hours with normal saline or 5 % glucosenormal saline or 5 % glucose

• Should not be given salicylates Should not be given salicylates for treatment of hypertermiafor treatment of hypertermia

Diabetic coma (DKA III stage)Diabetic coma (DKA III stage)

• An initial intravenous bolus of regular An initial intravenous bolus of regular insulin at 0.1 U/kg body weight, insulin at 0.1 U/kg body weight, followed by a continuous infusion of followed by a continuous infusion of regular insulin at a dose of 0.1 regular insulin at a dose of 0.1 U/kg/hour is the standard therapy U/kg/hour is the standard therapy (before 50 U of insulin should be (before 50 U of insulin should be diluted in 50 ml of normal saline – diluted in 50 ml of normal saline – than 1 ml will have 1 U of insulin)than 1 ml will have 1 U of insulin)

• When glucose decreased to 14 When glucose decreased to 14 mmol/L (250 mg/dL) – insulin can be mmol/L (250 mg/dL) – insulin can be injected subcutaneously (dose 1 injected subcutaneously (dose 1 U/kg/day).U/kg/day).

• If the patient is hemodynamically If the patient is hemodynamically stable, isotonic saline can be given at stable, isotonic saline can be given at a rate of 15-20 mL/kg/hour for the a rate of 15-20 mL/kg/hour for the first several hours. Once the serum first several hours. Once the serum glucose level is below 200-250 mg/dL, glucose level is below 200-250 mg/dL, the fluids should be changed to one-the fluids should be changed to one-half normal saline with dextrose (D5 half normal saline with dextrose (D5 1/2NS) given at a rate sufficient to 1/2NS) given at a rate sufficient to replace the free water loss induced replace the free water loss induced by the osmotic diuresis.by the osmotic diuresis.

Hypoglycemic comaHypoglycemic coma

• Glucagon (before 5 years 0,5 mg IM Glucagon (before 5 years 0,5 mg IM or SC< after 5 years – 1 mg IM or SC)or SC< after 5 years – 1 mg IM or SC)

• 20 % dextrose (D20) 1 ml/kg or 10 % 20 % dextrose (D20) 1 ml/kg or 10 % dextrose (D10) 2 ml/kg – during first 3 dextrose (D10) 2 ml/kg – during first 3 minutes, than 10 % glucose 2-4 ml/kg minutes, than 10 % glucose 2-4 ml/kg up to glucose level 7-11 mmol/L up to glucose level 7-11 mmol/L (glucose level should be checked (glucose level should be checked every 30 minutes)every 30 minutes)

Treatment of acute Treatment of acute adrenal adrenal (addisonian) (addisonian) crisiscrisis

• Hydrocortison (Cortef) IV 100 mg as a Hydrocortison (Cortef) IV 100 mg as a bolusbolus

• Intravenous saline and glucoseIntravenous saline and glucose

• Hydrocortison 10-15 mg/kg as a Hydrocortison 10-15 mg/kg as a continuous infusion for 24 hours continuous infusion for 24 hours Decrease one third of the Decrease one third of the hydrocortison daily dose every day hydrocortison daily dose every day until a maintenance dosage is until a maintenance dosage is reached within 5 daysreached within 5 days