Thyroid Emergencies (quick review)

submitted by Amit Kumar, M.D.

 

THYROID STORM

-Risk factors:

Longstanding untreated thyroid issues (Grave’s, toxic multinodular goiter, solitary toxic adenoma), but more commonly surgery, trauma, infection, parturition, recent iodine load

 

-Diagnosis:

Hyperpyrexia, AMS, cardiac dysfunction (tachycaria, A-fib, CHF, etc.) in a patient with elevation of T4/3 and supression of TSH

 

-Treatment:

• 1) Control increased adrenergic tone: B-blocker
  • PO: Propranolol 60-80mg q4-6h (monitor HR, BP)
  • IV: Esmolol 250-500mcg/kg followed by 50-100mcg/kg/min
• 2) Block new hormone synthesis
  • PTU 200mg q4h (safe during pregnancy) or
  • Methimazole 20mg q4-6h
• 3) Block further release of hormone
  • Iodine (1h post step 2, or else will be used to make more T4)
• 4) Inhibit peripheral conversion of T4 -> T3
  • PTU,
  • steroids such as hydrocortisone 100mg q8h (also treats relative assoc. adrenal insufficiency)

 

 

MYXEDEMA COMA

-Risk factors:

Acute event (ex: MI, cold exposure, sedative drugs such as opioids) in poorly controlled hypothyroid patient, drug induce (ex: lithium, amiodarone)

 

-Diagnosis:

Depressed mental status + hypothermia, hyponatremia, and/or hypercapnia (due to hypoventilation); hx of thyroidectomy scar or recent radioiodine therapy

Primary (with high TSH) or central (with low TSH)

 

 

-Treatment:

• 1) Thyroid hormone
  • Combined T4 (200-400mcg IV) and T3 (5-20mcg IV). Both are continued thereafter.
• 2) Glucocorticoids (until concominant adrenal insufficiency is ruled-out)
  • Hydrocortisone 100mg q8h
• 3) Supportive care
  • Non-dilute fluids (due to hyponatremia), passive rewarming, pressors (if hypotension doesn’t resolve)

 

 

References:

-Brunette DD, Rothong C. Emergency department management of thyrotoxic crisis with esmolol. Am J Emerg Med 1991; 9:232.

-Cooper DS, Daniels GH, Ladenson PW, Ridgway EC. Hyperthyroxinemia in patients treated with high-dose propranolol. Am J Med 1982; 73:867.

-Cooper DS, Saxe VC, Meskell M, et al. Acute effects of propylthiouracil (PTU) on thyroidal iodide organification and peripheral iodothyronine deiodination: correlation with serum PTU levels measured by radioimmunoassay. J Clin Endocrinol Metab 1982; 54:101.

-Jonklaas J, Bianco AC, Bauer AJ, et al. Guidelines for the treatment of hypothyroidism: prepared by the american thyroid association task force on thyroid hormone replacement. Thyroid 2014; 24:1670.

ultrasound visual aid: pillows, bags, and baths

quick tip for visualizing areas that are not flat planes (e.g. distal extremities, eyes, etc):

so you’ve probably heard about the gel “pillow” for ocular ultrasound (preferably with a tegaderm over the closed eye before adding the gel pillow)….

 

well, you can also try this quick tip via a recent ALiEM post:

try submerging (if feasible) the thing you want to visualize in a bath of water, or in a similar idea, throw an (intact) bag of saline or other IV fluid over it and then ultrasound through that as your medium.

 

add it to the toolbox.

 

References: gel pillow photo; ALiEM post with bath photo

SEIZURE PEARLS

submitted by Amit Kumar, M.D.

Generalized seizure

-Large parts of bilateral cerebral hemispheres involved
-LOC for the most-part. Post-ictal state (headache, drowsiness) common.
-Examples: Tonic-clonic (grand mal), absence (petit mal), myoclonic, tonic, atonic

Partial seizure

-Simple partial: limited to focal area in single cerebral hemisphere. Usually no post-ictal period.
-Complex partial: simple partial + LOC. Generally associated with an aura (smell, taste, visual hallucination, emotion). Post-ictal period common.

Status epilepticus

-Continuous seizure lasting over 5 mins/more than two discrete seizures without interval recovery

EtOh-withdrawal seizure

-Typically generalized, may begin within 6h of cessation/decreased consumption
-“Kindling phenomenon”: risk and severity of seizure increases (and threshold decreases) with each withdrawal episode

Febrile seizure

-Seizure in child (~3 mo-6y) with associated fever (>38C), without evidence of intracranial infection or other defined cause
-Types: Simple: Generalized, last <15 mins, don’t recur in 24h period; Complex: Focal, last >15 mins, recur in 24h period
-Subsequent epilepsy risk: simple (1-2%, only slightly above general population), complex (~5-10%)

Management

-ABCs, airway, O2, monitor
-If intubating: benzo for induction and short-acting paralytic (succ) to not mask ongoing seizures. Post-intubation sedation: benzo/propofol gtt
-Labs (check for electrolyte disarray, anemia), infectious workup, home anticonvulsant levels, neuroimaging prn
-Check POCG (dextrose for hypoglycemia), probe on abdomen (Mg for eclampsia), check drug-list (Vit B6 for INH toxicity)

Treatment

-Benzodiazepines (enhance GABA-mediated neuronal inhibition): lorazepam (Ativan), diazepam (Valium), midazolam (Versed)
-Phenytoin (reduces repetitive firing of action potentials via Na-channels). Administer IV/PO (rare)
-Fosphenytoin. Administer IV/IM
-Phenobarbital (enhances GABA)
-Valproic acid (increases GABA)

References

-Nelson KB, Ellenberg JH. Predictors of epilepsy in children who have experienced febrile seizures. N Engl J Med 1976; 295:1029.
-Rosen, Peter, John A. Marx, Ron M. Walls, and Robert S. Hockberger. Rosens emergency medicine: concepts and clinical practice. 8th ed. Vol. 2. Philadelphia: Elsevier Saunders, 2014. (& photo)
-Schaider, J. & Barkin, R. & Hayden, S. & Wolfe, R. & Barkin, A. & Shayne, P. & Rosen, P. (2011). SEIZURE, ADULT. ROSEN & BARKIN’S 5-MINUTE EMERGENCY MEDICINE CONSULT. Retrieved February 13, 2017 from http://www.r2library.com/Resource/Title/1608316300/ch0019s14706

WARFARIN REVERSAL – When and How?

submitted by Amit Kumar, M.D. 

 

SERIOUS LIFE-THREATENING BLEEDING:

-Hold warfarin

-Vit K 10mg IV infusion over 20-60mins

-PCC. Dosing based on weight and INR. Typical for INR >6: 50 U/kg. Re-check INR 30 mins post-admin.

-Transfusions: RBC, Platelets (if <50,000), FFP (15-30cc/kg; if PCC unavailable)

-Other agents: TXA/aminocaproic acid (anti-fibrinolytic), DDAVP (for platelet dysfunction)

 

URGENT SURGERY/PROCEDURE:

-Hold warfarin. Vit K + PCC, as above

 

SURGERY/PROCEDURE after 24H:

-Hold warfarin. Vit K 1-2mg

 

MINIMAL BLEEDING:

-Clinical judgement: withhold warfarin vs hold warfarin + Vit K vs more aggressive reversal (like above)

-Weigh pros/cons of current bleeding vs thromboembolic risk

 

NO BLEEDING:

-INR >9:  Vit K 2.5-5mg PO. Will reduce INR over 24-48 h. Can re-start warfarin (maybe reduced dose) when INR therapeutic

-INR 5-9: Hold warfarin temporarily (1-2 doses) +/- Vit K 1-2.5mg (elderly with slower clearance, prior bleeding)

-INR <5: Hold next dose of warfarin

 

SUPERWARFARIN POISONING:

-Often found in rodenticides, laced street-drugs. Accidental vs suicide attempt.

-Usually requires massive doses of Vit K (50-800mg/d) for months-years, based on repeat assays and coagulation studies

————————————————————————————————–

PCC pearls:

-If 4-factor PCC missing, use 3-factor PCC + FFP (to supplement factor VII)

-PCC dose based on units of factor IX activity

-PCC advantage over FFP: more rapid admin (doesn’t have to be thawed), faster INR reversal, lower risks for volume overload or TRALI

 

References:

–Ansell J, Hirsh J, Hylek E, et al. Pharmacology and management of the vitamin K antagonists: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008; 133:160S.

–Holbrook A, Schulman S, Witt DM, et al. Evidence-based management of anticoagulant therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e152S.

–“Paper Chase 1- PCC vs. FFP.” Review. Audio blog post. Www.emrap.org. EM:RAP, Dec. 2013. Web. <https://www.emrap.org/episode/december2013/paperchase1pcc>. Episode 147

–Schulman S. Clinical practice. Care of patients receiving long-term anticoagulant therapy. N Engl J Med 2003; 349:675.

–photo

 

DKA & HHS – treatment myths busted

submitted by Amit Kumar, M.D.

MYTH BUSTING:

*ABG >VBG: False, ABG = VBG.

Additionally, VBG is less painful and avoids complications like radial artery aneurysms, hematoma, and radial neuropathy. Lactate on VBG is equally reliable despite length of tourniquet time or temperature. pH of VBG is assumed to be 0.03 less than ABG. Only level missing in VBG are PaO2 and SpO2 (for which we have the pulse-ox). In general, ABGs are only useful in patient where knowing PaO2 is vital, and A-a gradient is desired.

 

*Shotgun insulin order s/p IVF: False. Correcting electrolytes is higher priority.

Serum K is low to begin with due to acidosis. Additional insulin and IVF will shift more K into cells, further depleting serum K. If K <3.5, replete K and hold insulin. If K 3.5-5.5, replete K with insulin. If K >5.5, may just give insulin.

 

*Insulin bolus, then drip: False.  Pediatric guidelines actually do not recommend bolus for potential risk for hypercorrection of serum glucose and cerebral edema.

Hypoglycemia is worse than hyperglycemia for mortality. So why do it? Per comparison studies, gtt at 0.14U/kg/h is better at providing a good therapeutic plateau, compared to 0.1U/kg bolus followed by 0.1U/kg/h gtt.
Replete Phos <1 mg/dL (vital for generating ATP) and Mg <2. Monitor Ca as well.

 

*HCO3 for pH <7.1: False. Bicarbonate exacerbates hypokalemia, and may even potentially increase risk of cerebral edema.

Bicarb also shifts O2 dissociation curve leftward, inducing hypoxia in a state of high demand. If given, just start a drip sans bolus, and mix with D5W (mixing with NS will cause precipitation and make solution hypertonic).

 

References:

*Kitabchi AE, Hirsch IB, Emmett M. Diabetic ketoacidosis and hyperosmolar hyperglycemic state in adults: Treatment. In: UpToDate (Accessed on July 27, 2016)

*Swaminathan A, Herbert M. (2013, May). DKA Myths [Audio podcast]. Retrieved from: emrap.org

*Wolfson AB, Hendey GW, Ling LJ, Rosen CL, Schaider J, Sharieff GQ. Harwood Nuss’ Clinical Practice of Emergency Medicine. 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2010.

picture

DENTAL BLOCKS (quick procedure review)

submitted by Amit Kumar, M.D.

Easy procedures providing big-time opioid-free relief!

Can mix 50-50 lido and bupivacaine for quicker onset + longer analgesia combo.

Infraorbital nerve block:

1) Topical anesthetic on cotton-tip swab/gauze to dried mucosa for 60 secs

2) Retract cheek, insert needle next to 2nd premolar, 0.5cm from buccal surface. Advance parallel to tooth

3) You’ll palpate it next to foramen (under palpating finger) at depth of approx 2.5cm

4) Confirm location, aspirate, then inject 2-3 cc local anesthesia

5) Massage tissue for 15 secs to hasten onset

*Intraoral approach provides nearly 2x duration of anesthesia compared to extra-oral approach

 

 

 

 

 

 

Inferior alveolar nerve block:

1) Topical anesthetic on cotton-tip swab/gauze to dried mucosa for 60 secs

2) Palpate coronoid notch with thumb, and stretch bucally (index & middle finger at angle of mandible outside)

3) Inject 2-3 cc of anesthesia at the site where middle of your thumb nail and pterygomandibular raphe biset

4) Massage tissue for 15 secs to hasten onset

*Will also anesthetize lingual nerve (anterior 2/3 of tongue in that side)

*Anesthetize long buccal nerve of that side, but injecting just distal and buccal to last molar

Reference(s):  Hedges, Jerris R., and James R. Roberts. Roberts and Hedges clinical procedures in emergency medicine. Philadelphia, PA: Elsevier Saunders, 2014. Print.

strength in numbers: blood transfusion risk

via a recent emdocs article (click through for the full read), some ballpark numbers that might help you when you consent your next patient for a blood transfusion:

<1% (~0.63%) had a transfusion reaction, based on data from 2011

only 317/8,000,000 (~ 1 in 25,000) had a serious reaction requiring ICU-level care

risk of viral transmission:

• HIV -> 1: 1,467,000 units
• Hepatitis C -> 1: 1,149,000 units
• Hepatitis B -> 1: 357,000 units

 

in comparison, for reference:

• odds of a royal flush (5-card poker): ~1 in 650,000
• odds of a four-of-a-kind (5-card poker): ~1 in 4000
• odds (in a single year) of dying in a motor vehicle accident: ~1 in 9000
• odds (in a single year) of dying in an “air and space transport” accident: ~1 in 770,000

 

References: emdocs article; poker probabilities; mortality risk