Keys to de-escalating endocrine emergencies


It’s a fine line between compensated and decompensated endocrine conditions, and often, there is an underlying non–endocrine component complicating the diagnosis.

That’s according to Marilyn Tan, MD, a clinical assistant professor of medicine at Stanford (Calif.) University, where she is chief of the endocrinology clinic. She spoke about endocrinology emergencies during a case-based, rapid-fire session at HM17.

“Endocrine emergencies are usually due to an excess or a deficiency of a hormone,” Dr. Tan said, noting that these can take time to bring into balance. This is one reason Dr. Tan counseled not waiting for laboratory results before administering treatment.

To diagnose and treat diabetic ketoacidosis, combined with a hyperosmolar hyperglycemic state, Dr. Tan recommended checking hypoglycemia levels, which she said are often mild, and to check anion gap, pH, and ketones. It’s also important to be generous with IV fluids, to administer insulin only if the ketoacidosis level is greater than 3.3 mEq/L, and to not take the patient off an insulin drip too early or inappropriately. To prevent readmissions, the patient on discharge should have adequate diabetes supplies, education on their condition, and timely follow-up, Dr. Tan recommended.

For patients experiencing a thyroid storm, Dr. Tan advised that thyroid function tests are a poor surrogate for predicting who will decompensate. The clinical distinction is made by documentation of acute organ dysfunction. Reducing T3 to T4 conversion means propylthiouracil is preferred over methimazole.

Ongoing management of a myxedema coma means monitoring the clinical parameters of the patient’s mental status, cardiac and pulmonary functions, while keeping the levothyroxine dose steady and checking lab values every 1-2 days to ensure the patient is progressing.

Suspect pituitary apoplexy in cases of hypertension, major surgery, trauma, anticoagulation, pregnancy, or if there is a large sellar mass. If choosing to image a patient, Dr. Tan recommended using an MRI rather than a CT scan, which she said is less sensitive. Immediate hydrocortisone treatment must be administered, she said. About 90% of cases of acute hypercalcemia are caused by hyperparathyroidism in the outpatient setting, and malignancy in the inpatient setting, Dr. Tan said. Also, these patients tend to be volume depleted, so assessment of their ability to tolerate hydration is essential.

Regarding all endocrine emergencies, Dr. Tan said, “When in doubt, be more aggressive with treatment.”

Dr. Tan had no relevant financial disclosures.

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