An article to understand the manifestations and treatment of endocrine crisis

Calcium crisis 1.

High-calcium crisis High- calcium crisis 1.

2.

tension

② heart vascular system: can cause high blood pressure, bradycardia or tachycardia, QT interval shortening, ST-T segment changes, can occur in severe fatal arrhythmia ;

Heart blood vessels arrhythmia

③ digestive system: loss of appetite, bloating, digestion and bad, constipation, nausea, and vomiting

Digestion digestive diagnosis

④ Urinary system: dry mouth, polydipsia, polyuria, nocturia; kidney stones, decreased renal function, etc.

⑤ Skeletal system: bone pain may occur in the early stage, vertebral compression, bone deformities may occur in the long-term, and pathological fractures may occur easily

3.

3.

Expansion

②Diacid salt application :

Diacid salt application

Zoledronic acid 4mg+100ml liquid intravenous drip for more than 15 minutes;

Pamidronate sodium 30～60mg+500ml liquid intravenous drip for more than 4h;

Iban sodium phosphate 2～4 mg+500ml liquid intravenous drip for more than 2 hours;

③ furosemide 40 ~ 60mg intravenously, cause urinary calcium excretion, while appropriate to add magnesium and potassium;

Furosemide

④Inject calcitonin 2～8U/(kg·d) subcutaneously or intramuscularly;

Calcitonin

⑤Hemodialysis or peritoneal dialysis reduces blood calcium;

Hemodialysis or peritoneal dialysis

⑥ Glucocorticoid (hydrocortisone or dexamethasone) intravenous infusion: it can reduce blood calcium in the short term, but long-term application will cause secondary increase in blood calcium.

Glucocorticoid

⑦The bedridden patients should move as soon as possible to avoid and alleviate hypercalcemia caused by long-term bedridden

Bedridden

Adrenal crisis

Adrenal crisis Adrenal crisis

2.

3.

②Rehydration: Generally, the body fluid loss of adrenal crisis patients is about 1/5 of the total extracellular fluid, so 2000-3000ml of normal saline should be supplemented on the first day, which can be estimated by 6% of body weight

③Anti-shock: People with shock symptoms should be given vasoactive drugs as soon as possible when fluid rehydration and glucocorticoid therapy still cannot correct circulatory failure

④ Etiology treatment such as anti-infection
.

⑤Symptomatic and supportive treatment

Pituitary crisis
1.
Incentives: various stresses, such as infection, diarrhea, vomiting, dehydration, hunger, cold, acute myocardial infarction , cerebrovascular accident, surgery, trauma, anesthesia and the use of sedatives, sleeping pills, hypoglycemic drugs, etc.

.

Pituitary crisis pituitary crisis
1.
Incentives: myocardial infarction

2.
Clinical manifestations:

2.
Clinical manifestations:

① Hypoglycemic coma: the most common, it is more likely to occur in patients with a deficiency of both glucocorticoid and growth hormone
.
The reason may be spontaneous, that is, caused by eating too little, or induced by insulin;

Hypoglycemia

②Infectious coma: patients with this disease are prone to infection due to low body resistance, and they are prone to shock and coma after infection
.
Body temperature can be as high as 40°C or higher, pulse rate often does not increase correspondingly, and blood pressure decreases;

③ Hypothermic coma.
This type of crisis often occurs in winter, with a slow onset and gradually entering a coma.
The body temperature is very low, which can be between 26 and 30 ℃;

④ Aquatic coma: Due to the lack of cortisol, the diuretic function is diminished.
It often occurs due to excessive intake of water.
The extracellular fluid is in a hypotonic state, causing excessive intracellular water and cell metabolism and dysfunction
.
The patient showed apathy, lethargy, nausea, vomiting, mental disorder, convulsions, and finally fell into a coma

⑤ Hyponatremia coma: the body cannot compensate for the loss of sodium due to gastrointestinal disorders, surgery, infection, etc.
, patients may experience peripheral circulatory failure, coma, etc.
;

⑥Sedation and narcotic coma: Patients with this disease are very sensitive to sedation and anesthetics, and the usual doses can cause the patient to fall into a coma or even a coma;

⑦Pituitary apoplexy : It is caused by acute hemorrhage of the pituitary tumor, with a rapid onset, and the patient has a sudden severe headache, stiff neck, dizziness, vomiting, and soon falls into a coma
.
Clinically, it is often mixed, manifested as a series of symptoms such as mental disorders, delirium, high fever or low temperature, nausea, vomiting, hypoglycemia, hypothermia, hypotension, coma and convulsions
.

Stroke

3.
Principles of rescue: Once a pituitary crisis is suspected, immediate treatment is required, and blood should be reserved for related hormones before treatment
.

3.
Rescue principle: Retain blood to be tested for related hormones

① To correct hypoglycemia , immediately inject a 50% glucose solution 40～80m intravenously, followed by an intravenous drip of 5% glucose and sodium chloride solution to correct hypoglycemia while losing water
.

Correct hypoglycemia

② Application of high-dose adrenal cortex hormones : Hydrocortisone is added to the fluid supplement, 200-300mg/d, applied in divided doses, or dexamethasone 5-10mg/d, applied in divided doses
.

High-dose adrenal cortex hormone application

③Correct water and electrolyte disorders : give 5% glucose and sodium chloride solution intravenously.
Patients with severely lowered blood sodium need to be given high concentration sodium chloride solution; record the patient's intake and output to avoid excessive infusion
.

Correct water and electrolyte disorders

④ Correcting shock : Hypotensive shock is very common in the crisis of hypophyseal hypofunction.
The lack of adrenal cortex hormones, water loss, hypovolemia, and hypoglycemia are important reasons
.
After the above treatment, most of the blood pressure gradually rises, and the shock is corrected without the need for blood pressure medicine
.
For some serious patients, the blood pressure recovery is not satisfactory after the above treatment, and the use of blood pressure drugs and comprehensive anti-shock therapy is still needed
.

Correct shock

⑤ Other : removal of incentives, infections are the most common, the most important incentive to choose according to the patient's antibiotic anti-infective therapy
.

Other antibiotics

⑥ Use sedatives, sleeping pills, anesthetics, central nervous system depressants and hypoglycemic agents with caution
.

Use sedatives, sleeping pills, anesthetics, central nervous system depressants and hypoglycemic agents with caution

⑦Patients with hypothermia should be kept warm with blankets , and a small dose of thyroid hormone should be given after the use of glucocorticoids
.

Keep warm

Hypothyroidism crisis (mucinous edema coma)

Hypothyroid crisis (myxedema coma) hypothyroidism crisis (myxedema coma)

1.
Incentives: It is more common in elderly patients who have not received treatment for a long time, and most of them get sick in the cold winter
.
Incentives mostly serious physical illness, interrupt thyroid hormone replacement, infection, surgery, use of anesthetics or sedatives
.

1.
Incentives:

2.
Clinical manifestations: lethargy, hypothermia (<35°C), slow breathing, bradycardia, drop in blood pressure, relaxation of limb muscles, weakened or disappeared reflexes, and even coma and shock
.

2.
Clinical manifestations:

3.
Rescue principles:

3.
Rescue principles:

①Remove the inducement and treat the primary disease
.

Remove the inducement and treat the primary disease
.

② supplement thyroid hormone : levothyroxine sodium (L-T4) for the first time 200 ~ 400ug, after the daily injections 1.
6ug / kg, after oral administration to the patient is awake
.
If there is no injection, nasal feeding with tablets can be given
.

Thyroid hormone supplement

③When possible, give the first dose of liothyronine (L-T3) intravenous injection of 5-20ug , and then maintain the dose of 2.
5-10ug/q8h
.

Liothyronine

④ Hydrocortisone is injected intravenously , 200-400mg/d, and the dose is gradually reduced after the patient wakes up
.

Hydrocortisone intravenous drip

⑤ Oxygen inhalation, heat preservation (avoid using electric blankets, which can cause blood vessel dilation and insufficient blood volume), keep the airway unobstructed, perform tracheotomy and mechanical ventilation when necessary
.

Oxygen inhalation, heat preservation (avoid using electric blankets, which can cause vasodilation and insufficient blood volume), keep the airway unobstructed, perform tracheotomy, and mechanical ventilation if necessary

⑥ Rehydration should be performed as needed , but the amount of water should not be too much, and the cardiopulmonary function, water and electrolyte, acid-base balance and urine output should be monitored
.
Hypercalcium crisis

Rehydration

Hyperthyroidism crisis
1.
Incentives:

Hyperthyroidism crisis Hyperthyroidism crisis
1.
Incentives:

①Infection: 3/4 of them are upper respiratory tract infections, followed by gastrointestinal and urinary tract infections, occasionally skin infections and peritonitis;

②Stress, hunger, mental stress, fatigue, drug reactions (drug allergies, digitalis poisoning, insulin hypoglycemia, etc.
), heart failure, hunger, disintegration, etc.

③Inappropriate disabling of ATD

④Preparation for hyperthyroidism is insufficient, or emergency surgery outside the thyroid gland, such as acute abdomen surgery, caesarean section, etc.

⑤ Occasionally after not fully prepared isotope therapy for hyperthyroidism
.

2.
Clinical manifestations: the original symptoms of hyperthyroidism are aggravated, followed by high fever, body temperature> 39℃; tachycardia, heart rate 140-240 beats/min, may be accompanied by atrial fibrillation or atrial flutter; irritability, shortness of breath, profuse sweating, Anorexia, nausea, vomiting, diarrhea, etc.
; late collapse, shock, delirium, and coma; some patients may be accompanied by heart failure or pulmonary edema, and occasionally jaundice; the total number of white blood cells and neutrophils are often elevated, and F3 and F4 are elevated.
TSH is significantly reduced; the severity of the disease is not parallel to the TH value
.
The case fatality rate of hyperthyroidism crisis is 20%
.

2.
Clinical manifestations: heart failure

3.
Rescue principles:

Rescue principles:

① suppression of thyroid hormone synthesis exhaust system : Preferred propylthiouracil (the PTU), the first oral dose of 600mg, with the PTU 20mg, 3 times a day smoked, like reduced therapeutic doses until the symptoms solution
.

Inhibition of thyroxine synthesis

② inhibition of the release of thyroxine : plus compound iodine oral solutions, the first dose of 30 to 60 drops every 6 to 8 hours after 5 to 10 drops

Inhibit the release of thyroxine

③ T4 to T3 conversion inhibit tissue and / or inhibiting T4, and cell receptor binding : PTU, iodine, and glucocorticoid receptor blockers, etc.

Inhibit the transformation of tissue T4 into T3 and/or inhibit T4, binding to cell receptors

④Reduce blood thyroxine concentration: hemodialysis, peritoneal dialysis or plasma exchange, etc.
can be used when the conventional treatment is unsatisfactory

Hemodialysis, peritoneal dialysis or plasma exchange

⑤ Supportive treatment : supplement calories and vitamins, correct the disorder of water, electrolyte and acid storage balance

Supportive treatment

⑥ symptomatic treatment , removal of incentives, including oxygen supply, prevention of infection
.

Symptomatic treatment

⑦After the hyperthyroidism crisis is controlled, an appropriate hyperthyroidism treatment plan should be selected according to the specific condition to prevent the crisis from recurring

Appropriate hyperthyroidism treatment plan

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