prehospital pain management · objectives review endocrine fundamentals highlight four icu...
TRANSCRIPT
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From Where?
Rochester, NY
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3 Days of Sunshine Annually
Invented SAD Lights
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Disclosures
I have no financial
disclosures
The feds want their
money back
The only bad
question . . .
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ObjectivesReview endocrine fundamentals
Highlight four ICU endocrine disorders
DM, CIRCI, hypothyroid, hyperthyroid
Discuss pathophys of alcohol withdrawal
Review the treatment options
http://medicscientist.com/hyperthyroidism-thyrotoxicosis-causes-symptoms-diagnosis
https://www.alcoholismrehab.org/alcoholism/how-many-heavy-drinkers-develop-alcoholism/s
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Endocrinopathy
Easy in the ICU
Call for help
https://www.staples-3p.com/s7/is/ http://www.lovelace.com/news/blog/endocrinology-–-thyroid-and-beyond
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Endocrine Fundamentals
Endocrine- hormones into bloodstream
Hormones
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Hormones
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Endocrine Fundamentals
Endocrine- hormones into bloodstream
Hormones
Act on target organs
Signaling for long distances
Prolonged duration
Delayed onset
https://www.theodysseyonline.com/20-things-to-do-when-your-bored
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The Pituitary Gland
Master gland
Controls other glands
https://www.nzgp-webdirectory.co.nz/Pituitary+Hormones.html
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The RestThyroid
Controls metabolism
Parathyroid
Ca2+ homeostasis
Thymus
T lymphocyte development
Pancreas
Glucagon(⍺), insulin(Β),
somastatin(δ)
PinealInternal clock
Adrenal
Norepi and epi
Aldosterone
Cortisol
Androgens
Ovaries and testes
Sexual development
https://en.wikipedia.org/wiki/Endocrine_system
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Diabetes
https://thenorwichradical.com/2016/09/07/immigration-the-elephant-in-the-room/
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Diabetes
98% easy
Insulin pump?
Acute pancreatitis
Shock liver
Feeding?
Steroids …https://nutrition.abbott/au/tube-feeding
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Adrenal Dysfunction
Primary stress response organ
Hemodynamic instability
Volume loss
Adrenal insufficiency
Caused centrally or peripherally
Present in up to 60% of ICU patients
Annane D, Maxime V, Ibrahim F, et al. Diagnosis of adrenal insufficiency in severe sepsis and septic shock. Am J Respir Crit Care Med. 2006; 174: 1319-1326.
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Causes of Adrenal Dysfunction
Exogenous steroid discontinuation
Inflammatory cytokines
Bacterial toxins
Medications (etomidate)
Adrenal hemorrhage
Increased cortisol metabolism
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Primary Symptom and Workup
Hypotension
ACTH(adrenocorticotropic) stim test
Draw serum cortisol, admin Cosyntropin
Draw serum cortisol in 60 mins
Expect cortisol to double to ~50 ug/dL
If cortisol ∆ < 9 or random < 10, + test
Will results change your plan …
Annane, D, Pastores, S, Rochwerg B, et al. Guidelines for the Diagnosis and Management of Critical Illness-Related Corticosteroid Insufficiency (CIRCI) in Critically Ill Patients (Part I): SCCM and ESICM 2017. Critical Care Medicine: Dec 2017; Volume 45(2). 2078-2088.
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Stress Dose Steroid Options
Hydrocortisone(gluc + mineralo)
Dexamethasone(gluc only)
Methylprednisolone(mostly gluc)
Prednisone(gluc + mineralo) PO only
Fludrocortisone(mineralo) PO only
D/C with BP resolution, wean?
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Critical Illness-Related Corticosteriod Insufficiency(CIRCI) SDS Guidelines
Part I
250µg Stim Test: Yes (poor)
Sepsis – shock: No (mod)
Sepsis + shock: Yes (poor)
Duration: > 3 days (poor)
ARDS: Yes (mod)
Major trauma: No (poor)
Part II
CAP: Yes, 5-7 days
(mod)
Flu: No (very poor)
Meningitis: Yes (poor)
CABG: Yes (mod)
Arrest: Yes (poor)
Pastores S, Annane, D, Rochwerg B, et al. Guidelines for the Diagnosis and Management of Critical Illness-Related Corticosteroid Insufficiency (CIRCI) in Critically Ill Patients (Part II): SCCM and ESICM 2017. Critical Care Medicine: Jan 2018; Volume 46(1). 146-148.
Annane, D, Pastores, S, Rochwerg B, et al. Guidelines for the Diagnosis and Management of Critical Illness-Related Corticosteroid Insufficiency (CIRCI) in Critically Ill Patients (Part I): SCCM and ESICM 2017. Critical Care Medicine: Dec 2017; Volume 45(2). 2078-2088.
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Thyroid Dysfunction
Walking into the mine field
T4- secreted by thyroid gland
T3- active form
Both are highly protein bound
Abnormal in 70 % hospital patients
Severely confounded in ICU
Adler S, Wartofsky L. The Nonthyroidal Illness Syndrome. Endocrinol Metab Clin N Am. 36 (2007), pp. 657-672.
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Why ConfoundedPlasma protein binding in acute illness
Free T4 levels are checked
TSH is time dependent
Distinguish between primary and secondary
disorders
https://clinicalgate.com/thyroid-abnormalities/
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Thyrotoxicosis
Primary hyperthyroidism
Autoimmune thyroiditis
Amiodarone
New onset AF
Tremulousness
Treated with beta blockers and
methimazole
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Thyroid Storm
Precipitated by surgery
Hyperthermia
Delirium
Hyperdynamic heart
Seizures
Death
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Diagnosis and Treatment
TSH is usually undetectable
Beta blockade
Traditionally propranolol
Metoprolol (more selective)
Esmolol gtt for severe cases
Thyroid suppression
Propylthiouracil (PTU) or iodine
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Hypothyroidism
Free T4 levels are low
Hashimoto’s thyroiditis
Surgical excision or radioiodine
Enlarged cardiac silhouette
Pericardial effusions
Lithium
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Myxedema Coma
Profound edema
Intradermal build up of proteins
Hypothermia
Altered LOC
https://www.pinterest.com/pin/16325617382599086/
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Treatment
Levothyroxine PO preferred
Dose adjustments weekly
Levothyroxine IV for myxedema
Wait 3-5 days to restart in ICU
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Melatonin
Reduce sedation needs
Restores circadian
rhythm
No clear
recommendations
RCTs are pending
Mistraletti G, Umbrello M, Sabbatini G, et al. Melatonin reduces the need for sedation in ICU patients: a RCT. Minerva Anesthesiol. 2015 Dec; 81(12):1298-1310.
http://crazyhyena.com/funny-kid-sleeping-on-a-dog
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Alcohol Withdrawal
Reduced GABAA stimulation
Reduced NMDA inhibition
Leads to CNS excitation
Agitation
Delirium
Seizures
http://9st.org/bum-researcher/
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Wernicke’s Encephalopathy
Low thiamine
Poor dietary intake
Administer IV dextrose
▼thiamine + D50 = Wernicke’s
Extreme B-vitamin depletion
Prophylaxis with thiamine
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Korsakoff’s Syndrome
Low thiamine
Korsakoff’s psychosis
Poor longterm prognosis
IV thiamine, nutrition, hydration
Positive treatment can take years
https://goinggentleintothatgoodnight.com/tag/wernicke-korsakoff-syndrome/
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Alcohol Withdrawal Timeline
6-8 hours
Anxiety, tremulousness, nausea
Professionals will seize
12-48 hours
Hallucinations
http://davidthebartender.blogspot.com/2015/08/drinking-hellfire-simple-guide-to.html
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Delirium Tremens
Usually 48-96 hours
Fever
Hyperadrenergic
Agitation
Altered LOC
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Care Plan
Rule out other etiologies
Quiet environment
Free from stimulation
May need restraints
Floor vs ICU
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ICU Admission Criteria
Broadly accept
Significant comorbidities
High doses of meds
Electrolyte problems
Concern for GI bleeding
Withdrawal related
seizures …
https://www.uptodate.com/contents/image?imageKey=PULM%2F73377&topicKey=EM%2F323&search=alcohol%20withdrawal%20treatment&rank=1~143&source=see_link
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CIWANV
Tremor
Sweats
Anxiety
Agitation
Auditory, tactile,
visual disturbances
Headache
Altered LOC
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Benzodiazepines
Start to treat for CIWA > 10
Gain control with frequent dosing
Every 10 minutes
Develop a maintenance plan
Insist on CIWA scoring
Avoid unnecessary medications
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Galton’s Rule for Benzos in ICU
Only two options
Seizures
Alcohol withdrawal
Apply liberally
PO diazepam
IV lorazepam
https://www.uspharmacist.com/article/treatment-of-alcohol-withdrawal-syndrome
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Phenobarbital
Work synergistically with benzos
Work OK independently
Dosing is 65 mg, 130 mg, 260 mg
Every 15-20 minutes
Makes anecdotal sense with GABAA
May require intubation
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Dexmedetomidine Infusion
Textbook dose 0.1-1.5 mcg/kg/hr
Not a respiratory depressant
Hemodynamic instability(> 0.7)
Tolerance in days
Lacking any significant evidence
ICU admission?
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Propofol
Mechanism of action
Strong respiratory depressant
Hemodynamic instability
May require intubation
Treatment vs anesthesia?
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Ethanol Infusion
NOT recommended
Poor titratability
End organ damage
Metabolic instability
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Review the Objectives
Review endocrine fundamentals
Highlight four ICU endocrine disorders
Discuss pathophysiology of alcohol
withdrawal
Review the treatment options
https://www.galveston.com/blog/573/stay-and-play-galveston-offers-gulf-fireworks-shows-every-sunday-this-summer/
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Thanks for Inviting Me
SAD Treatment Plan
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https://www.democratandchronicle.com/story/news/2017/03/15/latest-snowfall-totals-rochester-area/99202646/
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