What are inpatient endocrine emergencies?

Inpatient Endocrine Emergencies

Inpatient endocrine emergencies are life-threatening conditions resulting from hormonal deficiency or excess that require immediate recognition and treatment to prevent significant morbidity and mortality. 1

Common Endocrine Emergencies

Adrenal Crisis

• Adrenal crisis is a life-threatening emergency characterized by severe hypotension, shock, and electrolyte abnormalities due to acute adrenal insufficiency 2
• Clinical presentation includes:
  • Hypotension (often refractory to fluid resuscitation)
  • Nausea, vomiting, abdominal pain
  • Fever
  • Altered mental status
  • Hyponatremia and hyperkalemia 3
• Common triggers include:
  • Gastrointestinal illness with vomiting/diarrhea
  • Infections
  • Surgical procedures
  • Injuries
  • Severe allergic reactions 2
• Management requires:
  • Immediate administration of hydrocortisone 100 mg IV bolus followed by 100-300 mg/day as continuous infusion or divided doses every 6-8 hours 2
  • Rapid IV administration of isotonic saline (0.9%) at an initial rate of 1 L/hour 2
  • Endocrinology consultation for all patients 3

Thyroid Emergencies

Thyroid Storm

• Life-threatening condition characterized by severe thyrotoxicosis with multi-organ dysfunction 4
• Clinical features include:
  • Hyperthermia
  • Tachycardia/arrhythmias
  • Agitation, delirium, or coma
  • Gastrointestinal symptoms (vomiting, diarrhea)
  • Heart failure 4
• Management includes:
  • Beta-blockers (e.g., atenolol or propranolol) for symptomatic relief
  • Thionamides (methimazole or propylthiouracil)
  • Hydration and supportive care
  • Hospitalization for severe cases with endocrine consultation 3

Myxedema Coma

• Life-threatening form of severe hypothyroidism with altered mental status and hypothermia 4
• Clinical features include:
  • Hypothermia
  • Bradycardia
  • Hypoventilation
  • Hypoglycemia
  • Hyponatremia
  • Altered mental status or coma 4
• Management requires:
  • Intravenous levothyroxine
  • Supportive care including ventilatory support if needed
  • Careful fluid management
  • Treatment of precipitating factors 4

Diabetic Emergencies

Diabetic Ketoacidosis (DKA)

• Life-threatening complication of diabetes characterized by hyperglycemia, ketosis, and metabolic acidosis 5
• Clinical features include:
  • Hyperglycemia (typically >250 mg/dL)
  • Metabolic acidosis (pH <7.3, bicarbonate <18 mEq/L)
  • Ketonemia/ketonuria
  • Dehydration
  • Altered mental status 5
• Management requires:
  • Intravenous fluids
  • Insulin therapy
  • Electrolyte replacement
  • Treatment of precipitating factors 5

Hyperosmolar Hyperglycemic State (HHS)

• Characterized by severe hyperglycemia (>600 mg/dL), hyperosmolality, and dehydration without significant ketosis 6
• Clinical features include:
  • Extreme hyperglycemia
  • Profound dehydration
  • Altered mental status
  • Seizures
  • Focal neurological deficits 6
• Management includes:
  • Aggressive fluid resuscitation
  • Insulin therapy
  • Electrolyte replacement
  • Treatment of underlying causes 6

Severe Hypoglycemia

• Blood glucose <54 mg/dL with neurological symptoms 5
• Clinical features include:
  • Altered mental status or unconsciousness
  • Seizures
  • Autonomic symptoms (sweating, tremor, palpitations)
  • Focal neurological deficits 5
• Management requires:
  • IV glucose (D50W) for unconscious patients
  • Glucagon injection if IV access not available
  • Identification and treatment of underlying cause 5

Pituitary Emergencies

Pituitary Apoplexy

• Acute hemorrhage or infarction of a pituitary tumor resulting in sudden onset of headache, visual disturbances, and hormonal deficiencies 4
• Clinical features include:
  • Sudden severe headache
  • Visual field defects or vision loss
  • Ophthalmoplegia
  • Altered mental status
  • Hormonal deficiencies (especially adrenal insufficiency) 4
• Management includes:
  • Immediate high-dose glucocorticoid therapy
  • Neurosurgical evaluation for possible decompression
  • Hormone replacement therapy 4

Hypophysitis

• Inflammation of the pituitary gland, often immune-related, causing hormonal deficiencies 3
• Clinical features include:
  • Headache
  • Visual disturbances
  • Multiple hormone deficiencies (ACTH, TSH, gonadotropins) 3
• Management requires:
  • Corticosteroid replacement for adrenal insufficiency
  • Other hormone replacements as needed
  • MRI brain with pituitary cuts
  • Endocrinology consultation 3

Calcium Disorders

Severe Hypercalcemia

• Serum calcium >14 mg/dL or symptomatic hypercalcemia 4
• Clinical features include:
  • Altered mental status
  • Cardiac arrhythmias
  • Renal failure
  • Dehydration
  • Gastrointestinal symptoms 4
• Management includes:
  • Aggressive IV fluid resuscitation
  • Bisphosphonates
  • Calcitonin
  • Treatment of underlying cause 4

Severe Hypocalcemia

• Serum calcium <7.5 mg/dL or symptomatic hypocalcemia 4
• Clinical features include:
  • Tetany
  • Seizures
  • QT prolongation and arrhythmias
  • Laryngospasm
  • Altered mental status 4
• Management requires:
  • IV calcium gluconate for severe symptoms
  • Vitamin D supplementation
  • Treatment of underlying cause 4

Diagnostic Approach

• High clinical suspicion is essential as endocrine emergencies are often overlooked in critically ill patients 6
• Specific laboratory tests should be obtained before initiating treatment when possible:
  • Adrenal crisis: AM cortisol, ACTH, basic metabolic panel, renin and aldosterone 3
  • Thyroid emergencies: TSH, free T4, free T3 3
  • Diabetic emergencies: Blood glucose, ketones, arterial blood gas, electrolytes 5
  • Pituitary emergencies: Pituitary hormone panel (ACTH, cortisol, TSH, free T4, LH, FSH, testosterone/estrogen) 3
  • Calcium disorders: Total and ionized calcium, PTH, vitamin D levels 4

Management Principles

• Immediate recognition and treatment are essential to reduce morbidity and mortality 7
• Endocrinology consultation should be obtained for all suspected endocrine emergencies 3
• Supportive care including fluid resuscitation, electrolyte correction, and hemodynamic support is critical 6
• Specific hormone replacement or suppression therapy should be initiated promptly 2
• Identification and treatment of precipitating factors is essential 3

Special Considerations

Perioperative Management

• Patients with adrenal insufficiency require stress-dose steroids during surgery 3
• Recommended dosing: hydrocortisone 100 mg IV at the start of surgery, followed by an infusion of 200 mg/24 hours 3
• If recovery is uncomplicated, double the regular oral replacement dose for 48 hours and up to a week following major surgery 3
• Patients should be monitored for signs of under-replacement including hypotension, nausea, vomiting, and electrolyte abnormalities 3

Immune Checkpoint Inhibitor-Related Endocrinopathies

• Immune checkpoint inhibitors can cause various endocrine emergencies including hypophysitis, thyroiditis, and adrenal insufficiency 3
• Management depends on severity:
  • Grade 1-2: Consider holding immunotherapy until stabilized on hormone replacement
  • Grade 3-4: Hold immunotherapy, hospitalize patient, and initiate appropriate hormone replacement 3
• Endocrine consultation is recommended for all patients with suspected immune-related endocrinopathies 3