REBOOT: #372 Endocrine Emergencies featuring Dr. Sara Markley Webster

You're about to hear a classic curbsiders episode from our Hospital Medicine series on Endocrine Emergencies featuring Dr. Meredith Trubit and Moni Amine interviewing the great Dr. Sarah Markley Webster. So many great pearls in this one. So much practice changing knowledge, really what we're all about at the curbsiders. Now we're hard at work producing episodes and planning out the rest of our year, but during this summer, we wanted to reboot some of our favorite episodes from the past year or two. So if you haven't heard this one, definitely take a listen. But if you have heard it, as I said, it's so full of pearls, I bet you either missed some of them or you forgot them. So check it out for your space learning. But if you really need brand new curbsiders content, we're still releasing two new episodes every month over on our Patreon at patreon.com/curbsiders. And now we offer annual subscriptions, something people have been asking for. Maybe you can use your CME money for that, or you can sign up for the monthly subscription patreon.com/curbsiders. The curbsiders podcast is for entertainment, education and information purposes only. And welcome back to curbsiders. I am not Dr. Matthew Francootto, as you can already tell. I'm monia mean. And we're back with another inpatient episode. Join by my co-host Dr. Meredith Trubitt. How are you this evening? I'm doing pretty well. How are you? You know, I'm pumped. And they're about to find out why, but that's not relevant right now. What is relevant is on tonight's show, we discuss Endocrine Emergencies, a few that we haven't covered before. So DKA and hypercalcemia are episodes that we've already had. But tonight we do adrenal crisis, Mixed in macoma and thyroid swarm. With our guest, Dr. Sarah, Markley Webster, and in just a minute, Meredith is going to tell you a little bit more. But first, will you please remind the good people in the audience what it is we do on the show? Sure, Monie. We are the internal medicine podcast. We use expert interviews to bring you clinical pearls and practice changing knowledge. And tonight we have a fantastic conversation with our guest, Dr. Markley Webster. She is an endocrinologist at the Atlanta VA in affiliated with Emory University. She's a mom of two small human wild things. And one gigantic furry beast, aka her dog, who we talked a little bit about in the episode. Her main interest in training is in training education at all levels. And she particularly likes to work with the internal medicine residents to teach the endocrin topics they need to know for the boards. And also the ones they'll need to know for real life, which aren't always the same. She's a shy introvert, but it's excited to be on the podcast. And like Monie talked about, we're going to talk a little bit about thyroid storm and adrenal insufficiency and mixidimicoma. So without further ado, let's get to it. Hey Sarah, thanks for coming on the show. We're going to start with some rapid-fired questions and to start, we just can you give us your one liner? Yeah, so 35-year-old mom of two small petri dishes and one extremely large beast of a dog that keep me busy and chronically exhausted. What kind of dog? Great Pyrenees, and she's beautiful, and she knows it, and she gets into all kind of trouble because she knows she's beautiful. Oh nice. I'm the dog person. Monie can't handle the big dogs. No, I cannot. That means she would be your best friend if you came over and she would never leave your side ever. I prefer Meredith's dog regularly who stays away with the fun. She just stays away with a 10-foot pole, it's fantastic. Yeah, she has an anti-social personality. It's fine. That's why we picked. All right, so I think we'll kind of move through some of the openings questions kind of quickly. But I think the one that Monie and I really wanted to know from you Sarah was tell us a little bit of an example of good advice or feedback that you've gotten throughout your career during your training. Yeah, I think the best was when one of my attendings, I was really struggling with a patient, and I felt like we weren't connecting, and we weren't getting through, and we weren't hearing each other, and the attending was just like, "You know, Sarah, not everybody's going to like you, and not everybody's going to want to listen to you." And that's okay. And maybe sometimes we need to say, "Do we need to get a new doctor? Or do we need to get somebody else in here? Or do we need to just take a step back and realize that you're not going to be able to fix everything for everybody?" And I think that really helped me put some perspective in that my patients have a lot going on, and I have a lot going on, and we're not always going to be on the same page. And that's okay. And maybe next time it'll be better, or maybe next time it'll be worse. But that's not a reflection of me personally. So I think that really helped, because I was always like, "What am I doing wrong? Why can't I get across or get through to this person?" And so it really helped me take a step back from that. I think that's really good advice. I think especially physicians really are often people pleasing, and so it makes sense that we often feel like that is a breakdown on our end when in reality it's just life. And so I think that's like when we haven't heard of when we've done these shows so far, and it's really, that's really good advice. Moneem, do you want to jump into our pick of the week? So this is a shared one just because it's very, very ridiculously exciting. So friends, a couple of weeks ago I found this bright orange flyer on my door saying that there was this, it looked really sketch, I'm not going to lie. And it said that Netflix was making a show, and that they wanted to potentially use my house for the show, punchline, no, they did not use it, but they're using my neighbor's house. And the reason this is very exciting is who's involved with the project. So they are filming a series adaptation, mini series of the book, A Man in Full, directed by Regina King, starring Jeff Daniels, Diane Lane and Lucilo, and William Harper Jackson, which is from my favorite show, The Good Place. So very exciting and then today is happens to be filming day, so here are some weird noises. It's kind of probably related to that. The best part is I've had Regina King's sightings today, it's very exciting, I spoke to her. Tell everyone what you said to her. Not really Mary, but I feel like you're just setting me up, so what I had to tell Regina was, well first I said welcome to our humble abodes, plural. And then I just told her it was very exciting and then that was the end of the conversation and she continued to be a director of a multi-million dollar show on Netflix. I did, Meredith pointed out very kindly that I made it several hours before doing something so ridiculous. Yeah, I'm only kept it together until she didn't, and honestly I'm not going to lie, we're going to try to get through this so that we can catch a glimpse of Jeff Daniels because he is the star that will be in the scene that is being filmed at my neighbor's house. And there's a very awesome group thread with my friends, with pictures of us being creepy. So should we jump in? I think we're ready. I think we need to take it to our first case from Cashlack. Today we got Mr. Jerry first. He's a 68 year old man with a past medical history of heath path, asthma, type 1 diabetes, hypodrenalism, and he presents the emergency department with one day history of abdominal pain, nausea, and vomiting. So going to be real honest here, the hypodrenalism, I know is something important that I should know we should think about and do something about. And it's probably relevant to this case, but I think we should start by just like maybe having a brief conversation on definitions of hypodrenalism versus like adrenal crisis and what those differences are and how that might reframe how you're thinking about these patients. Yeah, so hypodrenalism or adrenal insufficiency depending on who you're talking to is just the person doesn't have the ability to make cortisol, right, whether it's a pituitary problem or an adrenal problem, their body is not functioning the way it should. And typically for a lot of people it's more of a chronic issue and so they're taking hydro cortisol or something like that as an outpatient. But when they come into the hospital, we get really concerned about adrenal crisis, which is where they could start having organ failure and they usually have hypotension and they're pretty sick. And it has a high mortality. Some studies state up to 40 percent if we don't treat or identify adrenal crisis early. And so whenever you have somebody who has any kind of adrenal insufficiency coming into the hospital, you always have to keep in the back of your mind, well, could this be adrenal crisis that's going on? And do I need to give them these high doses of steroids or do I need to treat this? Or is this something different? Is this an infection? Is this sepsis? Is this something else? But anybody coming in with the history of adrenal insufficiency or hypodrenalism should, you should have it in the back of your mind that maybe this is adrenal crisis? Thinking about kind of that definition is. It's all that's important for us to know kind of just that that is the lack of cortisol in the system Or is there more to the pathophys that matters kind of like when you're thinking about that spectrum at all? It matters a lot at the outpatient setting when I'm evaluating somebody for adrenal insufficiency Because I'm also looking at their mineralicorticoids and is this primary versus secondary because primary is much more likely to have a mineralicorticoid deficiency where they're going to be hyponatrimic and hypercanelamic and secondary not so much When they're coming into the hospital though, it's kind of moot because if they're coming into the hospital They're gonna need to be treated for the adrenal insufficiency and usually the doses of medications We use in the hospital cover both my glucocorticoids and my mineralicorticoids So it doesn't really matter that they don't have one or both or what have you Because I'm gonna be on to end up treating them either way I think that you actually covered a couple of the points that I think we were hoping we were trying to get to next But we're gonna take it back to Mr. Jerry for a second and kind of hit on the things that you did Maybe in a little bit more formal way so he's on further history He's worsening fatigue over the last week in conjection with that nausea vomiting and abdominal pain and His initial vitriols are significant for a temp of 385 heart rate 95 pp of 95 over 55 and he's saturating well on room air his Exam is notable for abdominal tenderness, but otherwise reassuring and his lab is notable for he's mildly hyponatrimic Sodium of 130 K of 5.9 calcium 11 glucose 75 and his CBC is notable for a white blood cell count of 10.7 You mentioned previously about, you know, we're thinking about infection sepsis adrenal insufficiency and I guess In a way, I guess I'm asking the threshold because I know I'm gonna be pumping in full of fluids Full of antibiotics because I'm, you know, just sort of gonna cover that base, but you know how what should my threshold for these Hydeosteroids be Pretty low, so when I have patients with adrenal insufficiency, what I tell them at home is If you have a mild illness like you have a sore throat, you have a runny nose something like that I want you to double up on your dose and if you have a fever Above 38 Celsius, I want you to triple up your dose and if you have nausea or vomiting where you can't keep down your pills I want you to come on into the hospital so that I can give you IV hydricortism and so when I have somebody coming into the hospital That's a pretty big stressor in and of itself not even including Whatever the precipitant is that's bringing them into the hospital the infection or the lack of glucocorticoids And so when I have somebody coming into the hospital, I have a low threshold to at least triple their dose But if I'm seeing things like hypotension, I'm seeing the nausea, I'm seeing vomiting even though it might be sepsis Maybe they ate some bad chicken or something the other day I still have a low threshold because the risk of not treating them is so much higher than the risk of giving them that 100 milligrams of IV hydricortis own and I really don't want to miss that person who's going to be in adrenal crisis and End up not treating them and have them be in the ICU for a couple of days when they would have had a much faster turnaround if I just given them the high-dose steroids And I think I missed it how much did you say you usually do like typically load somebody up? So we'll give them a hundred of IV Hydricortis own and then you can do something like 50 milligrams IV every six hours and Depending on the response kind of depends on how long you keep going with this if they turn it around in a day Well, then I'm going to start tapering fast and we'll go to 50 Q8 then 50 Q12 and we'll drop it down fast If they're not really turning around, I'm going to keep going with that 50 Q6 while we're trying to figure out What else is going on do they have some underlying infection is there an ammonia here that's contributing to this but what else is happening? And with doses that high if I give more than 50 milligrams of hydricortis own in a day I'm hitting both their glucocorticoid receptors and their mineralicorticoid receptors And so this is why we don't have to worry about things like fluid record is own in the hospital Because I'm typically giving more than that 50 milligrams of hydricortis own per day And so even if they had primary adrenaline sufficiency, I'd be covering Thermineralicorticoids anyway, and so we don't have stressed those fluid record is own or anything like that It's just the hydricort that we go with and that's why we prefer hydricortis own for stress doserates because it has the Glucocorticoid and the mineralicorticoid Something like dexamethasone doesn't have that and so you you want to stay away from something like dex The high doses they are usually used for like brain edema and things like that, but not so much for adrenaline sufficiency This podcast is brought to you by Grammarly Go One of the joys of this job is that I get to be creative I'm constantly working on talks or putting together podcast episodes But I can run out of this team sometimes and sometimes I've used a little bit of inspiration or something to kind of kickstart Me in the right direction, and that's why I'm happy to talk to you about Grammarly Go When it comes to writing with AI Grammarly is the expert for years They've been helping students and professionals harness the power of AI to perfect their writing wherever they are and now They're bringing you Grammarly Go to help you tackle your projects It's a new product that brings the capabilities of personalized AI to the Grammarly experience It lets you customize that you're writing to your preferred voice and goals so you can get through your to-do list more easily than ever before For instance one of the things that I've been sort of playing around with as I'm looking at Grammarly Go is how to refrain specific topics You know, I think on the curbsiders we talked about hypertension about 27,000 times So it's it's hard to come up with a fresh way to talk about it And you can just ask Grammarly Go You know, you can give it a problem to tell me an exciting way to frame talking about hypertension And it will give you a response and you can ask it to do that as many times as you need to to get inspiration to get moving forward It can also help you do things like write a cover letter if you're applying for a job You can generate this tailored cover letter that can be rewritten to reflect your voice and again emphasize the goals that you're trying to show off. 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And I'm not sure I ever remember that So I'm glad that you said that out loud so hopefully it'll stick auditorily for me The part about mineral cordicoids and glucocordicoids being in cortisone and then remembering that like Dexamethasone doesn't have that I think is something that I probably don't think enough about when I'm thinking about steroids And you know, stepping back just for a second with sepsis, adrenal crisis, those things I think kind of fit Is there anything else that you think about outside of those two when you see this and someone that has a known history of hypodrenalism? I mean, really it could be something just as mild as they've been chronically underdose and they've had a mild stressor Something that we wouldn't even think twice about like they got into a fight with a family member or they had a bad day at work So people who have been kind of borderline or marginal with their adrenal insufficiency and haven't been dose well Can actually tip into adrenal crisis with just minor stressors So it doesn't even have to be something big like sepsis It's what we always worry about but sometimes we really don't find much because it was a pretty mild stressor So we look, but that doesn't necessarily mean we're always going to get the answer Which is really frustrating when you're like I need to know what costs this so that I can tell you not to do it again So that this doesn't happen again Is there a set like dose that someone is typically getting in the outpatient setting or when you say under dose Is that because everyone's kind of on different doses? Yeah, so the dose for hydrochlorousone is very much dependent on somebody's body surface area And so standard replacement doses are seven and a half milligrams to ten milligrams per meter squared And so if you think about the average US male He's going to have a BSA of about 1.9 to two meter squared And so you would expect that he's going to need somewhere in the range of 15 to 20 milligrams of hydrochlorousone per day And because if you remember way back to physiology We know that cortisol has diurnal variation and I get that giant spike in the morning And then I get a milder spike in the afternoon before supper We'll usually split that dose up like two thirds or three quarters in the morning and the rest around four o'clock So if we're going to give him 20 milligrams I'd give 15 milligrams at breakfast and five milligrams in the evening And then see how they do if they're still having orthostasis or they're having abdominal pain and nausea will bump the dose up And so we'll try maybe 15 and 10 and see if that helps Or if they say it's wearing off early in the afternoon We might do 10, 5 and 5 to try to get their symptoms under control And so usually they're having a lot of discussion with their endocrinologist about how are their symptoms doing and are their symptoms under good control I just had somebody come in the other day and he was having nausea and All the time and GI had done this million dollar workup on him And he just needed an extra five milligrams of hydrochlorousone and his nausea was completely gone And so he'd been just mildly under dose but he would have been somebody who I'm going to be back. A small stressor could have tipped him into crisis and he would have ended up in the emergency department. - And along those lines about dosing in the outpatient setting, just so that I hear it, is there a need for prophylaxis in the situation of physiologic levels of steroids? I know you're laughing because we hospitalists just cannot seem to remember or keep it straight. So please help. - No, I actually really like that question because I was giving a lecture on this the other day and somebody asked me, they go, "At what point do you need prophylaxis?" And I was like, "Well, not my dosage usually." Like, that's a great question for ID because I'm always getting the steroids down and I don't want you on those high doses. But when you're thinking about prophylaxis, you don't have to do it for the physiologic replacement doses of hydrochlorous zone. So you're looking at those 15 to 20 milligrams. That's about what your body would make normally. And so that's not immunosuppressing you. But if you get up to higher doses, and so there's really good data that doses above 20 milligrams of prednisone, which five milligrams of prednisone is the equivalent of 20 of hydrochlorate. So we'd be talking about 80 of hydrochlorate. Doses above 20 milligrams of prednisone for more than three weeks are sufficient to immunosuppress you, and that's when you should be looking for PJP prophylaxis. And then glucocorticoid induced osteoporosis prophylaxis and things like that, but not usually at your physiologic doses for adrenal insufficiency. Now, I'm pretty sure all endocrinologists have those few adrenal insufficiency patients who just make their own hydrochlorous endoses, and they're on these sky-high doses, and we can't convince them to come down, but that shouldn't be the average person with adrenal insufficiency. - So now let's like go back to Mr. Jerry. And I think the way we framed like this case so far was like, hey, Mr. Jerry's coming in, you know he has this history of hypodrenalism, so like kind of how do you deal with that initially? But let's say he doesn't have that known history, and but sort of comes in the same way. So like still coming in with nausea vomiting, you're worried that this could be like sepsis. Kind of how do you, I mean, we talked earlier that like the adrenal crisis should kind of always be on your differential for these patients, just in case it's happening, but kind of what's your like tell-tale sign, or there are things that you're looking for on there, like history, physical, or there are specific labs that might point you more into that direction, like as you watch their course go. - Yeah, so some of it would be history dependent. So if you also said Mr. Jerry had a history rheumatoid arthritis or circuit, and had been on prednisone for weeks and had recently tapered off, well, adrenal insufficiency would rise much higher in my differential. But if he's just like we said, heart failure asthma, maybe not. Now the type one diabetes puts you in kind of a tricky spot because he has autoimmune disease, and autoimmune disease is tend to flock together. And so it's highly likely that he could also develop an autoimmune adrenalitis that ends up with adrenal insufficiency. So if I have somebody who has autoimmune disease already, and they're coming in nausea, vomiting, hypotensive, hyponatremic, hypercalemic, you've got to have could this be a new onset adrenal insufficiency, and this is a adrenal crisis, and I need to treat this. So there are some things in the history that I look for that make me think about adrenal insufficiency. But if I'm getting that hypotension, hyponatremia, hypercalemia, nausea, vomiting, abdominal pain, I mean, it's always gonna be in the back of our mind, right? 'Cause it's a can't miss diagnosis. And so the question I usually get is, how do I tell the difference? Like how do I diagnose this? Do I just give, do I just hand out the steroids and put 'em on and you figure it out later? Or what do I do here? And so I think that's a little tricky, because it really depends on when you're looking at Mr. Jerry, how sick do you think he is? If you think you can wait an hour before giving steroids, we'll go ahead and run a STEM test, and give him that 250 micrograms of ACTH and get a cortisol 30 and 60 minutes later and seek him as a adrenal function. It's not a perfect test, but it gives you some idea. But if he's looking pretty sick and you're worried, go ahead and give him the steroids. We can always figure out if he has a adrenal insufficiency down the road, and two or three days of high-dose steroids aren't going to cause him osteoporosis or give him PJP or anything like that. And so we can always come back and figure out if he has adrenal insufficiency. So if it's on your differential and you've got a suspicion, go ahead and treat it. We can figure out later whether or not he's actually got it. Because it didn't come up earlier with the patient with a known history of hypodrenalism, I think I might know the answer, but I'm wondering, this is the first time that you've mentioned the STEM test. So is this something that you don't even need to do in a patient with hypodrenalism or just, it might be a silly question. So typically, and somebody who has a known diagnosis of adrenal insufficiency, somebody's done some amount of workup, right? So they've gotten either that morning cortisol, that's so low that you don't have to do a STEM test, and that cut off varies a little bit for primary versus secondary. Or they've done the STEM test and the patient didn't STEM appropriately. And so somebody with a known diagnosis, we've done that workup. And we've probably challenged that workup a couple of times because all endocrinologists doubt each other and no one believes what somebody else says. And so if I have somebody coming to me and they're like, yeah, I've had adrenal insufficiency for 10 years, really, have you. Let's double check that. Maybe you've had recovery. So usually we're doing STEM tests not infrequently on them anyways to see if they've had any recovery of the adrenal glands depending on the cause. So it's mostly if I have a new diagnosis, or I think somebody might have been misdiagnosed, that I'm going for that STEM test. And it doesn't always end up being needed. You can use an 8am cortisol. And if that 8am cortisol is really low, you can avoid it sometimes. But for a lot of people, they're not coming in at 8 o'clock in the morning. And so my random cortisol level isn't particularly useful. I can only use it as a rule out test. So that random cortisol above 18 is what the guidelines say. There's some new data that says maybe 14 could be okay. But we say, standardly 18 says, yeah, you don't have adrenal insufficiency. You can make cortisol. But if there anything else, you're kind of stuck doing that STEM test. So you might as well just start with the STEM test so that you're not wasting time. - And I assume that regardless of whether you are, you know that this is adrenal insufficiency or not, the steroid dosing that we talked about before is like the same across the board. - Yeah, it's the same across the board. So when in doubt, when you're worried for adrenal crisis, you're going with those high doses of steroids just to cover your bases. - This podcast is brought to you by LocomStory. Everyone has a story, different needs, ones and goals, and how to attain them. Your story determines your solution. Whenever your situation and story, Locom tendons should be part of the conversation. How do you find out if LocomSt is a good option for you? Go to an unbiased informative source like LocomStory.com. You'll learn all the ins and outs of Locom's details on travel and housing, assignment coordination, tax information, and more. You'll also hear first-hand stories from Locom's physicians from all walks of life so you get a bigger picture of the diverse options. Get a comprehensive view of Locom's and decide if it's right for you at LocomStory.com. - And in terms of treatments, are there any other treatments that are like beneficial from a supportive standpoint that like us as a hospitalist would feel really confident in giving? - So like Moni said already, the things that you'd already be doing, right? Lots of fluids. These people tend to end up really volume down. And so you're gonna be giving a lot of fluids. You're gonna be covering with antibiotics while you try to figure out if they have sepsis. Typically, a lot of the electrolyte abnormalities are gonna resolve with the fluids and the glucocorticoids. And so hypercalcemia is typically just gonna go away when you treat the adrenalin-sufficiency and you give the glucocorticoids and with the fluids. So it's not necessarily something you have to focus in on and be like, oh man, I need to treat this calcium of 11. It's gonna get better with the treatment of the adrenalin-sufficiency. So it's mostly the fluids, the antibiotics, giving the glucocorticoids and trying to figure out what precipitated this. - And how fast do you typically see that resolution of their electrolyte abnormalities like next day or does it take a few days? - It kind of depends on how severe they are. So somebody with a sodium of 130, I expect I'd see pretty rapid recovery in that. Maybe in 24 to 36 hours or so, but I expect that I'd see that normalize pretty quick. It also depends on if they've got something else going on, right? So if they've got a pneumonia that precipitated this, whether it might actually be some underlying SIDH and that pneumonia, that's contributing with the hyponaturmia as well. And so maybe it wouldn't recover quite as fast as I would expect. So a little bit of that depends on what else is going on, but if it's just a, they were marginally dosed and they had some mild stressor that tip to them over, they usually turn around really fast. - Okay, and kind of along those lines, I kind of think about this in terms of discharge 'cause you're probably checking the meds a little bit more as you're discharging the patient. [BLANK_AUDIO] same as her Jerry's feeling better and he just wants to leave like he just keeps pasturing you. And he's overall improved. So what's your, you kind of mentioned that if they're getting better, you taper pretty quickly. What sort of things are you looking for to be like, okay, they're ready to transition home. And then like, what does that look like? Yeah. So usually, like you said, they're telling you, I'm ready to go home. Like, I'm feeling better. I'm feeling back to myself. I'm ready. And it kind of depends on how close I've gotten them back to their home dose, right? Because I did 50 Q6. Then usually it's 50 Q8, 50 Q12. I might go to 25 Q12 and my goal is trying to get back down to like 15 and 5. And so I might go 20 and 20 and then 15 and 15 and 15 and 10 and 15 and 5. So it kind of depends on where I am in this. If I'm at 20 and 20 and they're saying they're ready to go, I'm going to say, all right, tomorrow, you're going to take 15 and 15. The next day, you're going to take 15 and 10. And the next day, you're going to be back on your 15 and 5. And we review the sick day dosing every, I tell my patients, this should be reviewed with you every healthcare contact you get because it's so important. And it's the any sore throat, any runny nose, double up your dose, any fever above 38 Celsius, triple up that dose. And if you can't keep the pill zone, please come in sooner rather than later. Don't wait. The other thing I always check before discharge is do they have a medical or a bracelet or a dog tag? Because if they're in a car accident or they're ever found down, EMS needs to know that this person needs hydrocortisone ASAP. And they often have it in the ambulance and they can give it and route to the hospital. So I always check that my patient has some identification on them that will tell emergency workers, "Hey, you've got to give this person hydrocortisone." Great. I think you covered the counseling pretty well actually. So it seems like increasing the dose, telling them sort of went to increase the dose in the setting of any sort of stressor and then making sure they have a medical or bracelet. Are there any other sort of things that you like to tell patients as they're heading out the door to help prevent them from having to come back with this? Yeah, don't run out. That's often one of the big ones is don't wait until you have two days left to call me for a refill because I don't know that it'll get to you in time. And so I often also make sure that when I'm prescribing the tablets, I'm not prescribing just the number of tablets they need for maintenance. I'm usually throwing in an extra 50 or 70 tablets for a 90 day supply so that if they have those stressors, they have extra on hand and they don't have to worry about running out. And so I usually want to make sure they've got more than what they need because I'd always rather they take the tablet than not have the tablet and end up in the hospital. And I think this isn't intuitive but I think we made this point a lot in the on-emergency episode two. As the hospitalists, I'm not doing any of this alone, correct? Like these are not decisions I'm going to have to make. No. Endocrine is always more than happy and would actually probably be a little bit irritated if you weren't calling us about these patients and saying, "Hey, I have somebody with adrenal insufficiency coming in sick." That's a yeah, I'm going to go see them right now because I want to make sure that we're on top of all of the steroids and we've given the right amount of fluids and we've got the antibiotics and most endocrinologists are pretty obsessive about things. And so adrenal insufficiency is one of those things we we like to stick our fingers in and sometimes you might just find us there even if you haven't called us. I was going to say I'm not going to lie. I feel like you guys have a bat signal or something when your patients come in and I'm very grateful every time. Many of them have our direct cell phones or a way to send us a message to say I'm in the hospital so that we can be like, "I am coming. I will see you. I will be there." So definitely for my adrenal insufficiency patients, they know how to reach me. And then I just insert myself regardless of whether I'm asked or not. Appreciate the honesty. So I think we can recap a little bit because I think we touched on a lot of really helpful information. I think to start broadly, we're talking about adrenal insufficiency and adrenal crisis, which is for us in the hospital really just significant for the lack of cortisol that these patients have. And if you have any concern kind of for this happening, whether it is they have a known history or enough clinical clues in the emergency department to trigger you, to not hesitate and starting the hyposteroids. If you think the patient doesn't have a known history and you think that they can tolerate doing a test, go for it, but otherwise if you have any doubts, just go ahead and start the steroids and figure it out on the back end. And I think that's kind of the high points that we hit, Moni, do you have anything else to add? One of the things I liked that you kind of mentioned Sarah when we're getting ready to send people home is kind of let the patient be the guide. There's no need to force the issue about tapering them if they're already feeling better and their vitals and labs all look good. So I think that's a good thing to keep in mind because I think we all get a little cautious sometimes and listening to the patient can be helpful, shocking. Anything you want to add to our recap? Nope, I think you guys hit all of the big key points. I should mention that there is the option for stress dose steroids that you give continuously because there's relatively new data that came out that said maybe stress dose steroids, maybe they have a period where their levels still fall below physiology. And so there is an option that you can give continuous hydrocortisone through an IV when it's 200 milligrams over a 24 hour period and it's just a stable dose. But none of the hospitals that I've worked at have been able to do that successfully. So it's not something we typically reach for because pharmacy is usually able to hand out that 100 or 50 of IV hydrocortino troubles. And the delay and trying to have them figure out how to make the continuous hydrocortisone typically gives me a little bit of the PBGB. And so I just go for the, yeah, just give the IV 100 right now. And that way I know they've got something. But there is an option to do continuous hydrocortisone if it's available at your institution. Great. I think we are ready to go to our next case to Cashlack. Miss Nancy, she's 78 has a history of hypothyroidism, hefraff bipolar. She's been stable on her lithium for years. And she recently got started on amyotron for AFIM. She was brought into the emergency department by her family. They said that she's been disoriented, confused. Her vitals initially are notable for hypothermia. Her temp is 35. Her heart rate is 49. Blood pressure is 80 over 40, starting to panic a little bit. And her oxygen saturation is 91%. Her exam's notable for being lethargic. She's got some rails by basilarly and she has decreased deep tendon reflexes. Kind of similar to our last case with the known history of hypothyroidism, I feel like mixidima coma comes to the differential a lot faster in the situation. But one of the things I don't think I've ever fully appreciated is that there's a spectrum from hypothyroidism to mixidima coma. So what kind of helps you distinguish that? And kind of from physical exam and that sort of stuff. Yeah. So not going to lie, I get called not infrequently and they'll be like, Dr. Markley, this person's TSC is the highest I've ever seen. It is 200. I'm worried about mixidima coma. And what I usually tell people is if you saw this patient in your office and you didn't have labs, would you be admitting to them to the hospital or would you be sending them home? Because if you're going to send them home, they don't have mixidima coma. But if you're looking at putting them in the hospital, well, they very well might. And so that's kind of what my first cut point is. If they look clinically well, this is not mixidima coma because mixidima coma is a clinical diagnosis. It's not a biochemical diagnosis. It's not a lab diagnosis. It's a clinical diagnosis. And so it is, your patient has altered mental status. And you think this could be due to lack of thyroid hormone. And yeah, oftentimes you'll see things like hypothermia and bradycardia and hypoventilation, hyponeutremia. You have these other triggers that give you support. They also typically happen to be older females in the winter time. And so you'll kind of have this supporting information that says, yeah, this could very well be mixidima coma. And at the very least, there's no harm in treating it like it is because again, like all of the endocrine emergencies, mixidima coma has a pretty high mortality rate if we don't catch it and treat it. And so if it's crossing the back of your mind, it's worthwhile going down that path to see if it is and treating accordingly. I think the take home point here is coma is in the name people. So yes. Yeah. Now I have also had people tell me, I don't think this person has mixidima coma because they can talk to me. They're really slow. And they're very confused. But they can talk to me. Well, the coma part is really just their mental status is not at baseline. So you can be the thargic, not answering questions, well, not comatose and still have mixidima. coma, but you're altered in some way. But yeah, a lot of them are not not really giving you much. Okay, all right, I'll stop being snarky about that. The other piece to hypothyroidism or mixidima coma that I found to be interesting is if I recall correctly, maybe we maybe don't have the best understanding of the pathophys of this, we're doing it. Maybe I just don't. So, all right, I tell people that thyroid is kind of the gas pedal, well, TSH is the gas pedal of the body, and thyroid hormone is the gas. So you need it in order to maintain regular metabolic functions, to be able to control heart muscle contractions, regular muscle contractions, neuronal conduction, things like that. So if I don't have any, well, nothing runs. And so that's why I get the bradycardia because I don't have anything stimulating my heart to beat faster. And I get hypothermic because I'm shutting down my basal metabolic rate. I'm not metabolizing things to generate heat. And so some of it makes sense, right? And when I start shutting things down because I don't have enough thyroid hormone to run my body, that's when I start getting that organ failure. And the end organ damage and the organ failure is what I see is the hallmarks of Mixidima coma, right? When I'm having my brain start to failure, that's why my brain start to fail. That's why I start to get that altered mental status and heading towards coma. So it's a, I don't have any gas in my body. Nothing is running, nothing is working, and everything's going to start shutting down. And so I need to fill up the gas tank for this patient again. I guess like keeping all of that in mind, right? So you're thinking about all of this from kind of how the thyroid is affecting the body. We've established that this is entirely like a clinical diagnosis. The thing that I think I struggle with is that when I think of altered mental status as like such a key finding for it, I just feel like that's a huge differential that you're actually like thinking through. Are there any like scoring systems or any other like clinical aids to kind of guide you to say, yeah, this is more likely related to, you know, their hypothyroidism and this could be Mixidima coma versus something else that they also have. Yeah. And so I think there's some clinical findings that can really help point you in that direction. And so one is their speech changes. And it's really hard to describe if you've never heard a Mixidima speech, but it's kind of slow, thick, slurred speech like they've got a bunch of gumballs or something in their mouth and they're just not able to get the words out well and you can understand them with a lot of work, but it's work. They don't sound right. And their family members confirm this is not how they talk. And then you've got things like their reflexes, right? Which might not just be hyporeflexia, but a lot of that is just delayed relaxation of the reflex. That usually is a pretty good, yeah, this is something going on with low thyroid levels here because usually we're not having that delay in the relaxation. It's fast up, fast down. And that can be pretty subtle sometimes. It's much more obvious when they're truly in Mixidima, but sometimes it's best elucidated when you actually put your finger over the biceps when you're tapping so that you can feel the delay in the relaxation. They've got typically the Mixidima, right? So they have a Dima that's non-pitting that you're seeing. And then they've got their ridles that are all wonky, right? They're hypothermic, they're bradycardic, they can be hypotensives, and their electrolytes are getting all wonky too, with hyponutremia and things like that. And so it's kind of looking at the whole constellation of the patient because yeah, there's a lot that could be alter mental status, right? Could be infection and cephalitis, other things. But if it's on there, it's a fairly easy treat. And they should start getting better pretty rapidly. Typically people turn around within a day. I had somebody turned around within a couple of hours after he got his Livo thyroxine, and he was like, I feel like a new person, right? I believe it, man. I feel like a lot of endocrinologists might not even say, you know, this might not be Mixidima, but there's no harm in kind of giving them that extra dose of Livo thyroxine just to make sure and to get them bumped up to make sure that Mixidima is not contributing to any of this, right? Kind of similar to adrenaline sufficiency. It might be sepsis, but the risk of not treating adrenaline sufficiency way outweighs the risk of just treating. And so when I have Mixidima coma popping on my radar, I think most endocrinologists will lean towards, let's just go ahead and give them a dose of the IV Livo thyroxine, fill up the tank a little bit, take this issue off the table. This podcast is brought to you by Birch living. I have shared with you on the past how much I love sleeping, but despite that, I don't do as much of it as I would like. 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Right now, Birch is giving 20% off for all mattresses and two free eco-respose at [email protected]/@curb when you use the code BirchPartner20. Again, that is 20% off and two free eco-respose at [email protected]/curb when you use the code BirchPartner20. Sleep better with Birch. So I think that's a good segue. Let's talk a little bit about the thyroid replacement and treatment. Where do you start? Yeah, so the guidelines say we should start with IV leave-off our vaccine. And the reason for IV is because these patients might have gut edema, and so they're the bioavailability of leave-off our vaccine, and the absorption are not great as it is, right? It's super finicky. And so if I also have gut edema compounding that, I just want to avoid any absorption issues. And so we'll give IV leave-off our vaccine, and it's usually a loading dose of 200 to 400 micrograms. If my patient is younger, it doesn't have a lot of comorbidities, I'm going to err on the high side of that. If it's a little old lady, or they've got some heart history, I'm going to err maybe on the lower side of that with a 200 microgram dose. And so I'm going to give them a loading dose right now, and then what I'm going to end up doing is I'm going to be giving them every day after that 75% of their oral dose in IV form. And so that's going to get their levels up, and you can watch things to make sure this is working. So you can get a free T-4 level every 3/8 or so, and you can see that their levels are coming up. Typically, in mixed edema, they've got lower undetectable free T-4 levels, and so you can actually watch and say yes, we are in fact getting these levels up or treating them appropriately. There is some consideration that you can maybe give liathyronine or T-3 as well, in addition to levothyroxine. And most of us are really comfortable with levothyroxine. We have a lot of patients who have hypothyroidism, and we've given levothyroxine a lot, but liathyronine is not something we have as much experience with. And this is a pretty weak recommendation that the ATA gives, but there's some concern that in mixed edema coma, maybe you don't convert T-4 to T-3 as well in the periphery. And T-3 is the active form, so maybe we need to give a little bit of T-3 up front to kind of get over the hump of the mixed edema, get everything working again, and then we can let it go. So there's some thought that you should be giving 50 to 20 of liathyronine in addition to levothyroxine when you're first thinking about mixed edema coma, just to make sure that they have some T-3 to get things started. I was going to say the other thing for mixed edema coma is you always have to think about do they have concomitant adrenal issues, right? Lots of things in endocrine tend to go together, and so what you would hate to do is to have somebody who has mixed edema coma, and they also have adrenal insufficiency, right? They have auto-immune adrenaline sufficiency, and they had auto-immune hypothyroidism, and I don't treat the adrenal insufficiency because as if I try to kickstart my metabolism and I don't have any glucocorticoids on board, I'm gonna go into a adrenal crisis. So we often recommend that you give people stress those glucocorticoids as well to make sure you're not missing an adrenal insufficiency, even if they don't have a known history of AI. And we can figure out later do they need to stay on the glucocorticoids or not. But when you're treating for the mixidima, giving them that stress those glucocorticoids is kind of covering your bases to make sure you're not gonna tip somebody into a adrenal crisis right after they've been in a mixidima coma. - And I think you already said this part too, but I guess you can have variable lengths of improvement, like some people will improve pretty quickly and then some it might be a little bit slower kind of depending on severity that they came in known. - Yeah, so my little old lady who's got a lot of other comorbidities and has a pneumonia that precipitated her mixidima coma, I expect she's gonna take a little longer to turn around than my 40-year-old gentleman who just hasn't been taken his leave with iroxin because he didn't think he needed it and he got a cold and I give him his leave with iroxin and he turns around in less than a day. So it just kind of depends on what else is going on with the patient and what's their baseline health for how rapidly they turn around. But usually it's pretty quick. - Yeah, I think I remember in training at cashlacks that I had a patient. I think it was a communal patient, like everyone was trying to figure out was going on with the patient and I remember when some, there was like a eureka moment or something by one of my co-interns and they went down the mixidima treatment pathway and just like miraculous, the patient had like not been interactive for a while, a hot while and just it was incredible. So yeah, yeah. And it's amazing how people can compensate too. We've got people walking around with TSHs of 200s feeling fine and then you get them and leave out their oxygen and they're like, "Oh, I'm a different person." And you're like, "Oh, yeah, yeah, you are." - It's kind of that spectrum that we were talking about. - Okay, so I guess I'm curious now, you mentioned in the adrenal crisis part where you kind of listen to the patient about when they're ready to go home. What does that transition look like for patients with mixidima coma in terms of their leave of their oxygen and what's your, are you a little bit more conservative here or are you kind of similar like listen to the patient? I actually think I'm probably less conservative here than I should be and when I was a fellow I would get into some trouble for this 'cause I'd be like, "Ah, he's talking, he's eating, he looks better, let's just go to PO." We're good and my attending would be like, "What, what, I, no, I don't think so." So I still think it's a lot based on the patient and how the patient is doing, right? If they're talking to you normally, they're feeling better. I don't see any reason to continue with IV leave of their oxygen, right? If they're not having any edema that you're seeing, it's fine to switch back to PO. The downside to PO in the hospital is timing it is a huge pain, right? Because nursing wants to give all of the medications at the same time, which is typically right around breakfast time and leave both their oxygen like none of those things. And so you're usually timing it to be given at like four or five in the morning and then the patient's mad 'cause they're getting woken up at four o'clock in the morning to take their leave of their oxygen and then they can't fall back asleep. So I don't think there's really a right or wrong answer to how you transition. If it's easiest to keep on the leave of their oxygen, IV, fine. I would say if they've been in the hospital long enough that their 3, 2, 4 levels have normalized, you definitely don't need to be on the IV anymore. But it is easier from a nursing and patient perspective to give the IV because you don't have to worry about the absorption that you have to worry about with the oral. And in addition to telling them that you'll be seeing them in clinic, what other anticipatory guidance do you give them in terms of avoiding it or all those sorts of things? - Yeah, so it's mostly, again, take your leave of their oxygen, right? And one of the weird things about leave of their oxygen that doesn't hold true for a lot of our other medicines is if you miss a dose, you can double up the next day. It's all about the number of tablets per week because the half-life is so long. And in fact, if you're really poorly adherent with this medicine, I can have you walk into my clinic every Monday and do directly observed therapy of leave of their oxygen. And I will hand you all seven tablets and you will take them in front of me. And then I will get your TSH levels and show you that it really is just that you're not able to take the medication correctly. So it's a lot of just take the medication. And if you missed it, you forgot it, double up your dose. And I do have some people who take the medicine all on Saturday and they give me a little bit of palpitations because if they ever forget to take it on Saturday, they're gonna be in much bigger trouble than if they missed one dose, which is why we tell people to take it every day. But it's all about getting in the correct dose per week, the correct number of tablets per week. And so that's what I usually talk to people about is you've really gotta get this in. If you have to put it on your bedside table, so it's the first thing you see when you wake up, put it on your bedside table. Take it the moment you open your eyes. Then go shower, get ready for the day. By that time, you can take your other medicines and you can eat your breakfast. And then you're not having to worry about the absorption issues that come if they're taking it with calcium or iron or dairy products. Or you can take it right before you go to bed. As long as bedtime is two hours after your last meal, right? So again, you can have it on your night stand table. You're turning out the lights. You pop that super tiny pill of leave with a rock scene. It's itty bitty and you just take it. But you have to take it. Do we need to set alarms on your phone? Sure, do we need to have pill boxes where your family comes and helps you if patients struggling with memory impairment? Sure, but we've gotta get it in and you've gotta get it in consistently. And so that's the big thing that I really stress with patients and their families when they come in with mixidima is you really have to take this medication. You don't wanna be back here again. And just outside of taking medications, any other triggers they need to be aware of. That's typically the big thing is they haven't been taking it or they've been marginally adherent with it. And again, they're kind of on that cusp of they're able to hang in, they're compensating just barely, but any small thing tips them over. So the biggest thing is just getting the medicine in and making sure that they're following up to make sure their doses are correct. 'Cause we definitely have people who are taking the same dose. They were taking 10 years ago and you're like, that's not anywhere close to the right dose for you anymore. You've gained 100 pounds. We need to fix this. - Okay, I think we've covered a lot of ground here. So I think it's probably we're due for another recap for this section. You know, the first thing that comes to mind is the clinical diagnosis piece. And I don't think I had realized that, you know, there's like kind of a characteristic speech change that happens as potentially as a part of the altered mental status. So that was kind of interesting. And then, you know, the other piece in terms of treatment, you know, IV is done instead of oral because there can be a fair amount of guttedema and so that kind of sidesteps that part and gets the drug to the patient faster. Anything else, Meredith? - No, I thought that other interesting part was just 'cause we just talked about adrenal insufficiency kind of throwing on the steroids because if you start, I think as Sarah said, like increasing kind of the gas in their body, they're going to need something to keep them going and everything like that with the cortisol. - You'll find with endocrine and endocrine emergencies as long as it's not DKA, almost universally where you're advocating for throwing steroids at people. - Yeah, the autoimmune, it seems like autoimmune disease is kind of running gangs almost together. - They definitely do. And so always with somebody has any autoimmune disease, you're keeping thyroid, autoimmune thyroid, autoimmune adrenal kind of in the back, your autoimmune diabetes in the back of your head. - Cool, so Moni, you want us to jump to the next case? Case number three. - We got Miss Eleanor. She's a 74 year old woman with a history of hypertension and known hyperthyroidism. And she's admitted to the orthopedic surgery service because she fell at home and fractured her hip and orthos planning on operating in the next day for her. So they call medicines are like hey, she's got other medical problems. Can you help us with that? So when we were kind of thinking about Miss Eleanor originally when we were writing this case, we were like, hey, surgery, anesthesia, there's something with that with hyperthyroidism. But that was kind of the extent where Moni and I think stopped with our knowledge base. So can we talk through kind of what are like the potential triggers we should think about for thyroid storm in patients with hyperthyroidism? - Yeah, so surgery is one, definitely. And nobody wants to take a patient who has uncontrolled hyperthyroidism into the org because the risk of thyroid storm is so high, right? We don't want to stress people who are already having something going wrong. Like hyperthyroidism where they could be having a tachycardia or a fib or heading into heart failure or things like that. So most surgeons appropriately will not take somebody who has uncontrolled hyperthyroidism into the org unless it's an emergency, right? They're in thyroid storm and they're not responding to medical therapy and I have no choice but to get the thyroid out. And even then they're not going to be thrilled about it. They're going to be talking to you about, this is really high mortality. You know this, right? Are you sure you don't want to do this? Are you sure there's no other medication? you can use. You're medicine. Surely you have other medications. And so most surgeons and anesthesiologists are really cognizant of, yeah, you have a history of thyroid disease or you're on methamisole. We want to make sure you're doing really well and that everything is stable before we take you anywhere close to an OR. But again, just like adrenal insufficiency or mixidema, it's any kind of stressor, right? These people are kind of teetering on the edge, teetering on the edge, getting by just barely and any kind of stressor insult is going to tip them over into storm. And again, storm like mixidema coma and adrenal crisis has really high mortality. And so we'd like to avoid that if possible. I'm assuming you can correct this if this is going to be completely wrong, but in the way we're just talking about mixidema coma, hypothyroidism, essentially don't have enough thyroid hormone, like the thyroid storm is going to be kind of the exact opposite, I presume. Yeah, you're going 75 and a 30 mile per hour zone. And so everything's going too fast, right? You're tachycardic, maybe AFib, you're diaphoretic, you're hypothermic, you may be hypertensive. And so everything is just going too fast. Your GI tract is going too fast, you're having diarrhea, you're losing weight, even though you have a ravenous appetite and you're eating everything in sight. And so, right, that's hypothyroidism. And then the thyroid storm is where you've been going so fast for so long, everything starts to give up, right? So I'm getting my end organ damage. I'm getting liver failure. I'm getting heart failure. I have AFib with RVR. And so I'm starting to have my end organ dysfunction that is signifying that this is a much bigger issue now. And I need to treat this rapidly. I don't have time to wait anymore. So we were astute. We realized that this is a potential issue, this patient going into surgery. So what do we do to get on top of it before anything bad happens? Yeah, so ideally, we're going to have some time and we're going to delay the surgery if we can. Maybe not for this lady with a hip fracture. We probably can't delay this for a very long time. And so I'm going to get started with some medications to try to shut off the thyroid production. And so typically, that's a thyanamide, methamizal or purple thio-urusil, commonly called P2U because purple thio-urusil is a pain to save. And so I'm going to get started with a thyanamide, so you can't make thyroid hormone. And if I really need to take this patient into the OR, well, I can actually transiently shut off their thyroid by giving them iodine. So super saturated potassium iodine or something called lugal solution are both concentrated iodine. And if I give iodine, I can turn off the thyroid for a short period of time where I've saturated all the receptors, everything shuts down. It's not releasing any thyroid hormone. Now two or three days after that, it's going to start making a whole bunch of thyroid hormones. So I really need to make sure my methamizal is on board already. But if this person really needs to go to the OR, I'm going to give some methamizal. I'm going to give some of this SSKI to shut off their thyroid. It also reduces the vascularity of the thyroid if they're going for like an emergent thyroid ectomy or something. But those are going to be my best options to try to get this patient through their surgery safely. Okay, so let's say that we don't know the patient has hyperthyroidism or we just maybe it slipped our mind that surgery hyperthyroid bad. What does that look like? And then what do I do to fix that on the back end? Oh, so it kind of depends, right? This patient may fly through really well, right? If it's a young grave's patient, not Miss Eleanor, who's 74 with a hip fracture. But if it's a young grave's patient, they might come through surgery just fine. But the older you are, the more chromabinities you are, the less you have the ability to compensate, right? So the higher risk you are of something bad happening. And so there's not a great way to predict who if they're going into surgery is going to end up in thyroid storm. And I am not ever in the or so I have never seen this happen. But in talking to some of my ear nose and throat colleagues, they've said, you know, the surgery will be going fine. And then all of a sudden the patient is crashing and it can happen early in the surgery within the first 30 minutes or it can happen towards the end when they're getting ready to close up and they thought everything was fine. And so the auntie surgeon I was talking to said hyperthyroidism is one of the things that scares her the most because she doesn't have any way to predict is this patient going to do fine or is this patient not going to do fine. And there was some data that said thyroid storm happens equally often if the patient is hyperthyroid or you thyroid on their medications, which is terrifying from our perspective because if it happens even if they're you thyroid on medications, how exactly am I supposed to prevent this from happening and how am I supposed to best optimize them. And the answer is we don't really know. And so they could fly through, they could do really poorly. And there's not a great way to predict which one they're going to do. We've kind of talked a little bit about, you know, treatment on the back end in the situation where a patient has had thyroid storm. And I think this is a running theme and you kind of addressed in the last case. But can we talk again about steroids? I don't think I've ever talked about steroids so much to be honest. Yeah, I always find it a little bit ironic for somebody who is always trying to get people off of steroids. How much I talk about how we need to put them on for some people. So all right. So we're talking about our patient has had this terribleness happened in the OR. They've gone into storm. They're having the signs of end organ damage. They're not doing well. We're giving them medications. And we talked about methamizal and SSKI before to try to minimize risk. But after when we've kind of hit the fan, and we're doing more often PTU now. And so I'm going to give PTU. I'm going to keep going with my iodine. And then I do have to give my glucocorticoids again. And again, we're going with my stress dosing glucocorticoids saying, you know, again, storm, hybrid iridism, autoimmune disease most commonly for many people, graves disease. And so I'm worried that there could be a component of adrenalin sufficiency going on here. And I want to make sure I'm not going to precipitate in adrenal crisis. So I'm going to give my IV hydricortisone again. It also gives me an extra benefit because hydricortisone inhibits T4's conversion to T3 in the periphery. So it helps decrease the amount of active thyroid hormone I have floating around in the blood, causing me problems. And then that same vein, I'm also going to want to be giving a beta blocker. And so the recommendation is for Esmolol or Proprienolol. Proprienolol is probably what's most commonly used in the US. And so I'm going to be giving Proprienolol to slow down the heart rate or help with the A5 and keep them rate controlled. But it also inhibits peripheral conversion of T4 to T3. And so I'm reducing my active hormone with Proprienolol as well. And so Endocrine has a garbage mnemonic for this called the five bees, which is the worst mnemonic I've ever heard, because literally each one of the bees is block. And so it doesn't help you in any way shape or form. And so it's blocks synthesis with your thionamides. Block peripheral conversion with glucocorticoids, block peripheral conversion with beta blockade, block release with iodine, and maybe block hepatic circulation with colosteramine. But that's not so much used anymore. But it's a terrible mnemonic. But whenever you talk to any endocrinologist, they'll be like, oh, the five bees, and you're like, it's just block. They're all block. Yeah, so I have a soapbox on that mnemonic. It drives me crazy. But yeah, they're getting glucocorticoids too. And so they're getting the same, they're getting the stress dose just like we're giving for mixidima, coma, and adrenal crisis, just to make sure that we're covering our bases. And is there any other supportive care to like provide them? Because at least the beta blocker feels like that's definitely within my realm that I would feel more comfortable with. You know, the others, I'm definitely just asking endo to help me with dosing and things like that. But are there in the way that there were fluids for like adrenal insufficiency? Are there things like that we should think about? So if they're really hyperthermic, great things like aggressive cooling can be used. But again, I'm not sure how much that would be you pulling that trigger versus me pulling that trigger versus us looking at each other and being like, what do you think? Should we cool this guy? Sure, let's give him a try. It's not going to hurt anything. But that would be maybe the other thing that I would think about is depending on how hyperthermic they are, you might need to aggressively cool this person. And you might end up giving your beta blocker as a drip instead of like a PO medication just so that you can control it more readily. And you can go up and down much more easily as they're improving. You can start backing off faster. But I think a lot of the time it's mostly endocrine sitting over there running the show saying, no, yeah, we're going to keep going with this for a few more days. Or, oh, no, I think they're a little bit better. We can maybe talk about switching back or cutting back on our doses. or weaning off, but yeah, I think those are the big things. - And how long until you would see improvement in these, I'm assuming it's the same as the other cases, but this one's actually got some data behind it. So they should have proved within 24 to 48 hours. And if they're not improving with our therapies and 2 to 48 hours, they need something better. And so whether that's a thyroidectomy or plasma ferrisis, but if these medications aren't working at 48 hours, you have to do something else because they're now extremely high risk of mortality and you need to do something. And so the surgeons are gonna want you to do plasma ferrisis. You're gonna be running down to talk with your colleagues about plasma ferrisis, and they're gonna be like, "I've never plasma ferrisis for thyroid storm," because most of us have never plasma ferrisis for thyroid storm. And so you're all gonna be kind of chewing your fingernails, watching this patient very nervously, while you figure out if plasma ferrisis gonna work or are they gonna have to go to the OR because they're high risk of death without going and they're high risk of death with going. And I've gotta do something. - So when you get to that 48 hour time point, I would think that time is just kind of of the utmost importance also for the patient. And so often when I think of plasma ferrisis, I think of that as just usually like a little bit more logistics have to go into it than how I think of maybe the patient going to the OR. And so does that plan to the decision at all? - Honestly, this has not been a point that I've had to get to. Usually if I'm hitting that 24 hour mark and I'm thinking about something, I've already got my ENT surgeon that I've talked to, and I've already gone down and talked with my nephrologist, who's gonna be doing my plasma ferrisis for me. And we've all kind of sat there and been like, not me, not me, not me, 'cause nobody wants to do any of these things 'cause they're scary and really high risk. And fortunately our patients have always kind of turned around by that 48 hour mark and we haven't had to go ahead with plasma ferrisis, but I'd say it is something where you wanted to involve your consultants early to say, hey, I have this really sick patient and they may very well end up needing plasma ferrisis or a thyroidectomy. And so I'd rather you get on board sooner so that if we need to pull the trigger on this, there's no delays. It's not a, you're not in the hospital, you've never heard anything about this patient, you're gonna come see them tomorrow kind of situation. It's a, we've already talked about this and we've already got a plan for what we're gonna do. So I'm usually getting people involved sooner rather than later. - Yeah, I think that's helpful, especially for this scenario where like the time frame is so clear, helpful to like know that even within 24 hours if you're not seeing improvement to maybe start getting the ball rolling and expecting some of those things that might be logistically more challenging. I think that, I don't know, at least as a hospitalist, I feel like that's my one role is to make sure logistics happen in the hospital. And so that's like, I think really helpful to know. - Sticking with Ms. Eleanor, let's say she got better within her like 48 hours. How do you now start thinking about transitioning her out of kind of that scary time into the rest of her hospital stay as well as to home? - Yeah, so that's usually a taper of the PTU and a switch over to Mithemizal. And it's a pretty easy switch. 10 milligrams of Mithemizal is 100 of PTU. And so you're trying to get them over to Mithemizal for kind of long term is outpatient because it has much less risks than the PTU does with the PTU having risks of liver injury. And so you're getting them switched over. You're trying to make sure that you have their heart rate down under 90 and then you're gonna switch your beta blocker to some kind of XL beta blocker to try to improve adherence. And typically they're gonna go on the Mithemizal and the extended release beta blocker and they're gonna have rapid follow up because their levels are gonna start dropping. And I don't wanna end up with somebody floorily over treated who has a TSH of 200. And so they're gonna have rapid follow up and endocrin clinics so that we can make sure we're backing off on their doses appropriately and that we're not over treating them and that we're not making them brainacardic and they're walking around with a heart rate of 40 and they needed their perpranolal dose halved. And so they're gonna see me typically within four weeks after they leave. So it would be the same time like 'cause I always think of thyroid as like recheck it in four to six weeks. Like it's kind of my reflex. So it would be the same sort of timeline almost. It's still that four to six weeks I guess. - Typically that's when I have that follow up. It's four to six weeks and I've kind of been keeping an eye on the 3-T-4 while they're in the hospital so that I know that they're turning in the right direction. And usually that's soon enough that I haven't tipped somebody over into fluorid hypothyroidism although I can't say that's never happened. But usually that's a pretty good timeframe to be able to see them back and keep tweaking their medications. - And let's say they were seeing their primary care they got follow up like within a week. It's is it worthwhile to check like thyroid again that soon or would you almost always wait the four weeks to see? - They're they're gonna freak out. So it happens not infrequently that that happens. At their post this church visit somebody gets full TFTs and then they're calling me going, you need to see this patient right now. And it's a no no, I know their levels don't normalize overnight. We have them on medication. Are they having new symptoms? No, great, okay. So they're just gonna come back and they're gonna see me and they have my number or my contact information to get in touch with me if they start having symptoms again. But right now this is just their levels haven't been shut down for long enough, right? We have it blocked production with a thalamine for long enough. This is still the leave of the thyroxine they had in their system. It's gonna take them in it for that to come down. And so don't don't ever check the TFTs within a week of hospital discharge. That hospital discharge follow up, TFTs should be disallowed. They should not be allowed to be clicked because you're just gonna freak out about them. Even if it was something like recovery from non-thyroidal illness, right? It's gonna look wonky and then somebody's gonna freak out about it. So no TFTs at the hospital discharge follow up. - What anticipatory guidance would you give? - So that one's hard, right? Because a lot of things that trigger thyroid storm, we don't have great information for who's gonna get triggered or who's not, right? We know infection increases your risk, surgery increases your risk, but I don't have great ways to predict for this. So a lot of the times, if I have somebody who's had thyroid storm, we're talking about definitive therapy because I'm not playing this game with you. We're not gonna play around with methamizal and getting your levels knocked out. No, we're just gonna definitively treat you because you're not going into thyroid storm again. And so we'll talk about radioactive iodine versus a thyroidectomy when their youth thyroid is an outpatient, but this isn't a, this is one of those times that I'm very clear that I'm not okay with continuing to prescribe methamizal long term. You were really sick. You were critically ill, you could have died. And we don't ever want this to happen again. And so we're gonna do definitive therapy to make sure that it doesn't happen. And for the most part, people are like, yeah, no, I never wanna go through that either. I'm 100% on board with this plan. You do what you have to do. And so it works out well for the most part. Occasionally I get somebody who's wanting to be very holistic and natural and doesn't like the idea of taking thyroid hormone replacement. And that's just a conversation of, you're gonna be taking something either way. And hypothyroidism is much safer than hypothyroidism. And so if we have to pick a poison, let's pick the one that's much safer and it's less likely to kill you. We didn't touch on one thing for thyroid storm. Maybe deliberately on my part, but that would be the birch mortovski score that I always get quoted when people call me for thyroid storm. And they'll be like, their birch mortovski score is 45. And this is a scoring system that just gives you points for different signs of thyroid storm. So like tachycardia and hypothermia and altered mental status. A fib, any nausea or vomiting or abdominal pain. And I tell people, I meet criteria for thyroid storm when I walk up two flights of stairs at the hospital. And so it's not specific. It doesn't tell you that yes, this is a hundred percent thyroid storm. It tells you this could maybe be a thyroid storm. And so it's not something to hang your hat on and the diagnosis. So it's good for helping you think about the end organ damage that you're looking for with thyroid storm. But just 'cause they have those things does not mean that they're in storm, right? Like I said, I meet those numbers by going upstairs. So it's something to take and use with a grain of salt if you're gonna be using a scoring system for thyroid storm. - I actually think Meredith and I looked at that when we were reading and literally said the same thing, which is pretty easy to get those points and seems maybe not the best tool in really any situation. - So everybody, it's right. It's in the scoring systems that people look at when they search for thyroid storm. And so everybody wants to calculate it, but it's just a keep in mind. It doesn't mean that they actually have. thyroid storm. It just means it should be on your differential. Yeah, I think it's like, I think where it's valuable is like making sure you're having it kind of in your differential and like thinking about it because it's like a camp misdiagnosis. But yeah, I think I was on service and looked at my list and I was like 70% of my patients meet this criteria today. Like this isn't actually like as helpful in that scenario. And I think they did a study that looked at scoring people with that score and found that it called thyroid storm in 20% to often. And I was looking at that study and I was like, I think your study is flawed because I'm pretty sure it calls it far more often than just 20% to often. All right. So, Moni, you want to jump into a recap of some thyroid storm? When you think about patients with thyroid storm or have a history of hyperthyroidism specifically in situations with surgery, it's really important to be on top of it ahead of time. And generally done with PTU, mythomizol, iodine. And then on the back end, if you happen to maybe not put all that together, it's really important to make sure that you're engaging all the appropriate consultants, obviously end in chronology. And in the situation where a patient, you know, doesn't improve with treatment within 48 hours, they would potentially need something like a thyroidectomy or plasma frisis, so getting all those folks on board. And then, you know, one of the things that I also found interesting is I think that running theme for all of these is that there's just like clinical diagnosis, a whole heck of lot more important than a scoring system or a lab or any of that. And I feel like that rang true all the way through capping it off with a birch wortov ski score. No, I think you nailed it. So Sarah, do you have any, do you want to go through some take-home points that you want to make sure all the listeners got? Yeah, so I think the biggest thing is looking at your patient, right? Because none of these you can hang your hat on lab diagnoses. And so, or biochemical findings. And so it's a, if your patient looks well, they probably don't have one of these. But if your patient looks it, they very well might. And it's better to hedge your, to hedge your bed and say, let's treat them like they do rather than miss one of these diagnoses because the mortality rate is so high. So again, patient looks well. I don't care that their TSH is 200. They're not in Mixed Emacoma. But you could have somebody who went into Mixed Emacoma with a TSH that's pretty close to normal, right? It just depends on their ability to compensate and what other comorbidities they have. And so it really depends on how your patient looks. But if these are running through your brain, it's always safer to treat them not. This has been another episode of the curbsiders bringing you a little knowledge food for your brain hole. Yummy. Get your show notes at the curbsiders.com and sign up for our mailing list to get our weekly show notes in your inbox. Plus twice each month, you'll get our curbsiders digest, recapping the latest practice changing articles, guidelines, and news and internal medicine. We're committed to high-value practice changing knowledge. And to do that, we need your feedback. So please subscribe, rate and review the show on Apple Podcasts for Spotify or email us at [email protected]. A reminder that this and most episodes are available for free CME credit for all health care professionals through VCU Health at curbsiders.vcuhealth.org. Emeritus and I really enjoyed putting this episode together with our whole team. The curbsiders is produced and edited by the team at PodPaste. Elizabeth Frodo runs our social media, Stuart Brigham, composer of the music. I've been Monia Memean. And as always, I've been Dr. Meredith Elizabeth Trubit. Thank you and good night.