Podcast # 428: Severe Hypothyroidism

Author: Gretchen Hinson, MD

Educational Pearls:

  • Clinical manifestations of severe hypothyroidism may include:
    • Pale, cool, diaphoretic skin
    • Myxedema is the non-pitting edema seen in hypothyroidism
    • Hypothermia, heart failure, hypotension and shock
    • Shortness of breath
    • Cholestasis, constipation
    • Encephalopathy and coma

 

Mortality is 30-50%

Specific treatment includes thyroid hormone (T3, T4, or both) and glucocorticoids (for potential adrenal insufficiency)

 

References:

Kwaku MP, Burman KD. Myxedema coma. J Intensive Care Med. 2007 Jul-Aug;22(4):224-31. Review. PubMed PMID: 17712058.

Ono Y, Ono S, Yasunaga H, Matsui H, Fushimi K, Tanaka Y. Clinical characteristics and outcomes of myxedema coma: Analysis of a national inpatient database in Japan. J Epidemiol. 2017 Mar;27(3):117-122. doi: 10.1016/j.je.2016.04.002. Epub 2017 Jan 5. PubMed PMID: 28142035; PubMed Central PMCID: PMC5350620.

Lee CH, Wira CR. Severe angioedema in myxedema coma: a difficult airway in a rare endocrine emergency. Am J Emerg Med. 2009 Oct;27(8):1021.e1-2. doi: 10.1016/j.ajem.2008.12.027. PubMed PMID: 19857436.

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Podcast # 421: Sweet DKA Pearls

Author: Gretchen Hinson, MD

Educational Pearls:

  • Diabetic ketoacidosis patients are subject to electrolyte derangements
  • Potassium should be monitored closely:
    • K < 3.3 = Do not give insulin and replete K first
    • 3.3 < K < 5.3 = give 20-30mEq K for each L of IVF
    • K > 5.3 = delay potassium replacement
  • Adult patients are typically severely volume depleted and can require 50 cc/kg bolus or more
  • Insulin typically given in bolus of 0.1 units/kg followed by drip at 0.1 units/kg/hr

 

References:

Fayfman M, Pasquel FJ, Umpierrez GE. Management of Hyperglycemic Crises: Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar State. Med Clin North Am. 2017 May;101(3):587-606. doi: 10.1016/j.mcna.2016.12.011. Review. PubMed PMID: 28372715.

Nyenwe EA, Kitabchi AE. The evolution of diabetic ketoacidosis: An update of its etiology, pathogenesis and management.Metabolism. 2016 Apr;65(4):507-21. doi: 10.1016/j.metabol.2015.12.007. Epub 2015 Dec 19. Review. PubMed PMID: 26975543.

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Podcast # 417: Water Balance

Author: Katie Sprinkle, MD

Educational Pearls:

  • Hyponatremia results when patients over hydrate and dilute their sodium with too much free water
  • Symptoms of hyponatremia can mimic symptoms of dehydration (dizziness,  lightheadedness, general malaise)
  • With severe hyponatremia patients can progress to seizure, coma, and death
  • Hypernatremia results from dehydration and is more common

References:

Bennett BL, Hew-Butler T, Hoffman MD, Rogers IR, Rosner MH; Wilderness Medical Society.. Wilderness Medical Society practice guidelines for treatment of exercise-associated hyponatremia: 2014 update. Wilderness Environ Med. 2014 Dec;25(4 Suppl):S30-42. doi: 10.1016/j.wem.2014.08.009. PubMed PMID: 25498260.

Braun MM, Barstow CH, Pyzocha NJ. Diagnosis and management of sodium disorders: hyponatremia and hypernatremia. Am Fam Physician. 2015 Mar 1;91(5):299-307. PubMed PMID: 25822386.

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Check out this episode!

Podcast # 371: EKG changes of Hyperkalemia

Author:  Jared Scott, MD

Educational Pearls:

  • EKG changes do not necessarily correlate to degree of hyperkalemia
  • Traditional progression through peaked T-waves, flattened p-waves, QRS widening, and then sine-waves before asystole

References

Mattu A, Brady WJ, Robinson DA. Electrocardiographic manifestations of hyperkalemia. Am J Emerg Med. 2000;18:721–729.

Podcast # 346: Pediatric DKA

Author: Chris Holmes, MD

Educational Pearls:

  • There is a risk of cerebral edema in pediatrics with DKA if over resuscitated.
  • Recent study comparing normal saline vs. ½ normal saline showed no difference in rates of cerebral edema regardless of rate of infusion.
  • Recommend sticking with a fluid resuscitation protocol you are familiar with (i.e., 2 rounds of 10cc/kg bolus of NS).

 

References

Glaser, N. S., Ghetti, S., Casper, T. C., Dean, J. M., & Kuppermann, N. (2013). Pediatric Diabetic Ketoacidosis, Fluid Therapy and Cerebral Injury: The Design of a Factorial Randomized Controlled Trial. Pediatric Diabetes, 14(6), 435?446. http://doi.org/10.1111/pedi.12027

Podcast #310: Bicarb in DKA

Author: Gretchen Hinson, M.D.

Educational Pearls:

  • Controversial topic.
  • Pathophysiology – acidosis leads to an extracellular potassium shift. Patients in DKA will be intracellularly potassium deplete, but will have a falsely normal/elevated serum potassium.
  • 3 risk of giving bicarb in DKA – alkalosis will drive potassium intracellularly but can overshoot (hypokalemia) and  increase risk of arrhythmias; bicarb slows clearance of ketones and will transiently increase their precursors; bicarb can cause elevated CSF acidosis.
  • 3 instances when appropriate to give bicarb in DKA: DKA in arrest; hyperkalemic in DKA with arrhythmia; fluid and vasopressor refractory hypotension.

References:

Bratton, S. L., & Krane, E. J. (1992). Diabetic Ketoacidosis: Pathophysiology, Management and Complications. Journal of Intensive Care Medicine, 7(4), 199-211. doi:10.1177/088506669200700407

Chua, H., Schneider, A., & Bellomo, R. (2011). Bicarbonate in diabetic ketoacidosis – a systematic review. Annals of Intensive Care, 1(1), 23. doi:10.1186/2110-5820-1-23

Podcast #292: Hypercalcemia

Author: John Winkler, M.D. 

Educational Pearls

  • Normally, the parathyroid is the master regulator of serum Ca levels. It secretes PTH, which stimulates calcium uptake from the bone and gut.
  • Causes of hypercalcemia include: parathyroid tumor, lytic bone lesions (multiple myeloma), breast cancer, renal injury, and some lung cancers.
  • Hypercalcemia can lead to poor bone quality and pathological fractures. It can also cause heart arrhythmias.
  • It is important to order an ionized calcium to quantify the level of hypercalcemia, since calcium binds to albumin.
  • Treatment for hypercalcemia includes fluids and loop diuretics.

References:  https://emedicine.medscape.com/article/766373-treatment

Podcast #290: The Biochemistry of DKA

Author: Dave Rosenberg, M.D.

Educational Pearls

  • DKA commonly causes hyperkalemia, leading to peaked T-waves on ECG. However, DKA causes hypokalemia at the same time.
  • In DKA, glucose cannot be taken into the cells. This signals the body to create and use acidic ketones for energy. This leads to acidosis. To compensate for increased acid, H ions are pumped into cells. To maintain electroneutrality, K is pumped out of the cell. At the kidney, K is lost in the urine.
  • Overall, while serum K is high in DKA, total body K is low. The derangement in K can lead to life-threatening arrhythmias.
  • Treatment for DKA can induce hypokalemia, as the K will shift back into the cells with insulin administration. Therefore, treatment for DKA needs to include K.

References:  http://www.merckmanuals.com/professional/endocrine-and-metabolic-disorders/diabetes-mellitus-and-disorders-of-carbohydrate-metabolism/diabetic-ketoacidosis-dka

Podcast #186: IV Contrast

Run Time: 2 minutes

Author: Aaron Lessen M.D.

Educational Pearls:

  • Regularly a patient’s creatinine level is an important factor in determining whether a patient will receive IV contrast with a CT because it is thought that contrast can harm the kidneys and could worsen underlying kidney disease.
  • A recent retrospective study compared the rates of worsening kidney problems between patients who received a CT scan with contrast, a CT without contrast, and no CT.
  • The study even included patients with creatinines of up to 4 before excluding patients.
  • The study suggested that there is no difference in the rate of worsening kidney problems between the three groups.

References: http://www.annemergmed.com/article/S0196-0644(16)31388-9/fulltext

Podcast #181: Electrolyte Emergency

Run Time: 5 minutes

Author: Peter Bakes, MD

Educational Pearls:

  • Calcium is ubiquitous ion in the body necessary for bone, muscle, and nerve function
  • Hypocalcemia is associated with tetany (elicit Chvostek’s sign and Trousseau’s sign) and irritability
  • Hypocalcemia can progress to seizures and prolonged QT which can cause cardiac arrest
  • Hypocalcemia can be caused by vitamin D deficiency
  • Patients with malabsorption are at risk of vitamin deficiencies

Link to Podcast: http://medicalminute.madewithopinion.com/electrolyte-emergency/

References: http://emedicine.medscape.com/article/241893-overview

http://www.mayoclinic.org/diseases-conditions/short-bowel-syndrome/basics/definition/con-20037215