Case #2

[Bostonredsox]

Had this roll in last week.

81 y/o. to ED from SNF with dyspnea. Gets some Bipap in ed because ph 7.17 co2 62. tad bit encephalopathic(unknown baseline) and weak. looks like the typical 81 y/o SNF pt. (shi%^y). was at home, broke his hip a month ago, been rehabbin' in snf ever since. He cant tell you much cept hes cold and having trouble breathing.

Temp 92.3, WBC 7k, H/H ok, HR 41 and sinus, BP 75/55, bun/cr 65/3.1 up from baseline of 40/2.0. Anasarca on exam. Lungs relatively clear. IJs completely collapse on inspiration in t'berg. IVC looks small on bedside US. CXRY looks clean. Cardiacs negative. EKG sinus brady.

Go.

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[sluggs]

1. What are goals of care?
2. What is his albuminn?
3. What is his sodium?
4. What does a 300 ml bolus do to him?

 

[Phlegm]

1) Start with a liter of NS IV bolus
2) Warm him up
3) Go ahead and send the TSH if he's not hyperkalemic or on a beta blocker or CCB, hasn't overdosed on pain meds, or if his heart rate doesn't improve with normothermia

 

[Bostonredsox]

1. What are goals of care?
2. What is his albuminn?
3. What is his sodium?
4. What does a 300 ml bolus do to him?

Goals unknown, full code, no family present just a neighbor from when before he was in NH.
albumin was 2.7 on arrival
sodium was 133
ED 1L bolus improved systolic a small amount.

 

[Bostonredsox]

1) Start with a liter of NS IV bolus
2) Warm him up
3) Go ahead and send the TSH if he's not hyperkalemic or on a beta blocker or CCB, hasn't overdosed on pain meds, or if his heart rate doesn't improve with normothermia

He was given the bolus
They put blankets on him but 2 hours made no change, still 92-93
They DID send the TSH....but only because it comes on the dyspnea/CHF panel that was his working diagnosis. When I talked to him myxedema was not mentioned.
He is on nadolol.
No CCB, no narcotics
they could not achieve normothermia

 

[VentdependenT]

So what would you do if the TSH was 14?

 

[Bostonredsox]

So what would you do if the TSH was 14?

It was 11. T3 2.1 T4 lower limit of normal

any other questions or thoughts for workup/trt before I start telling how the story played out.

 

[VentdependenT]

Fluid on warmer. gimmie rest of lytes and lactate. based just on gas looks like combined metabolic and respiratory acidosis.

Anyways lets focus on etiology of hypothermia here.
-top of list is severe sepsis: pan cx, sv02, procal, lactate.
-then malnutrition: glucose, albumin
-then cardiopulm: bedside echo
-then endocrine: am cortisol. IVF and pressors and just consider trial of hydrocortisone.
-maybe nursing home left him on bathroom floor allnight....

 

[jdh71]

Had this roll in last week.

81 y/o. to ED from SNF with dyspnea. Gets some Bipap in ed because ph 7.17 co2 62. tad bit encephalopathic(unknown baseline) and weak. looks like the typical 81 y/o SNF pt. (shi%^y). was at home, broke his hip a month ago, been rehabbin' in snf ever since. He cant tell you much cept hes cold and having trouble breathing.

Temp 92.3, WBC 7k, H/H ok, HR 41 and sinus, BP 75/55, bun/cr 65/3.1 up from baseline of 40/2.0. Anasarca on exam. Lungs relatively clear. IJs completely collapse on inspiration in t'berg. IVC looks small on bedside US. CXRY looks clean. Cardiacs negative. EKG sinus brady.

Go.

With that gas there is more going on than just a resp acidosis, so at some point I'd like to see the whole set of lyte - my guess is you're holding some back to draw out the case more

I treat this old mental statusy guy like sepsis until something better comes along. He'd get a tube. He'd get a few liters of warmed saline. He'd get some norepi. He'd get some abx.

The TSH is off, but I'm not buying myxedema from that t3 and t4.

I'd like to know the rest of my lytes, and a lactate. It'd be nice know a random cortisol. Probably check lower extremity U/S too just make sure I'm not finding any thombus. Bedside echo to check the RV, and formal echo to get pulmonary pressures.

 

[glorfindel]

Temp 92.3, WBC 7k, H/H ok, HR 41 and sinus, BP 75/55, bun/cr 65/3.1 up from baseline of 40/2.0. Anasarca on exam. Lungs relatively clear. IJs completely collapse on inspiration in t'berg. IVC looks small on bedside US. CXRY looks clean. Cardiacs negative. EKG sinus brady.

Hypothermia, bradycardia, hypotension, MS changes, anasarca, renal insufficiency

Sepsis
Adrenal insufficiency
Myxedema

Gimme a K+

 

[jdh71]

 

[VentdependenT]

And what would you do if T4 was low?

 

[jdh71]

And what would you do if T4 was low?

Low? I think we'd have our diagnosis. Would give the IV thyroid juice. Though myxedema coma like DKA usually has some kind of OTHER inciting medical problem. So the rest of my management wouldn't change.

 

[VentdependenT]

Low? I think we'd have our diagnosis. Would give the IV thyroid juice. Though myxedema coma like DKA usually has some kind of OTHER inciting medical problem. So the rest of my management wouldn't change.

Would it be THE diagnosis? TSH not that high. again all hypothetical.

 

[Hernandez]

Would it be THE diagnosis?

I'd be the ******* to argue, absolutely not, myxedema with a tsh of 12?.

Without any other data, and playing odds, if anything combo severe sepsis plus euthyroid sick syndrome with adrenal insuf. Go nuts, check a reverse t3, free t3, t4, random cortisol,

Agree mostly with JDH
Tube,
Line,
30-40mL/kg fluid then pressors
Random cortisol,
Thyroid data,
Lactic,
Active warming measures (while 92 is technically still mild,) if he ain't shaking, he's clinically moderate hypothermic, a blanket ain't going to cut it.
+/- stress dose hydrocortisone
And abx
Back to call room.
Page me with labs

 

[jdh71]

Would it be THE diagnosis? TSH not that high. again all hypothetical.

The TSH isn't normal, and I'm unaware of a cut off point where we decide its "high enough" to be interesting. It's not >20 is that your problem?

If the TSH is high and the t3/t4 are low in the setting of mental status changes, hypothermia, hypotension, bradycardia, and hypoventilation, it's a myxedema coma likely secondary to something else, probably an infection somewhere. Would be nice to see the sodium and glucose.

 

[jdh71]

Alternatively, you could just diagnose this as just a really bad cold. Lots of fluids, blankets, and rest. q8 chicken noodle soup. A few grams of vitC per day - can't hurt anyone.

 

[Hernandez]

The TSH isn't normal, and I'm unaware of a cut off point where we decide its "high enough" to be interesting. It's not >20 is that your problem?

If the TSH is high and the t3/t4 are low in the setting of mental status changes, hypothermia, hypotension, bradycardia, and hypoventilation, it's a myxedema coma likely secondary to something else, probably an infection somewhere. Would be nice to see the sodium and glucose.

Without a reverse t3, I'm very underwhelmed by the tsh of 12, it's not that uncommon to see in ICU pts as euthyroid sick Syndrome isn't uncommon. However, my personal approach would be to look at random ACTH, if it low, I'd emperically treat both hydrocortisone and levothyroxine until rT3 is back, just because of the frequency of hypothyroid & and hypoandrenalism is present.

It's good to have this in the back of your mind, but it ain't that common. I've only had 1, and I don't now if you were involved in the case at your IM joint, the pulm PD was bragging about having a case when I interviewed there. I've had several "textbook" presentations of old people in ED, hypothermic, bradycardia, hypotensive, altered, hypercarbic with Hyperkalemia....and they all have normal to mildly elevated tsh but turn out to be septic that respond to septic treatment alone without any levothyroxine. I got snippy with a ER resident several months back as they presented that to me on the phone and I wondered out loud if this was the case and the ***** replied the pt is only groggy, not comatose. "Really? And here I didn't realize that coma was part of the diagnostic criteria."

 

[jdh71]

Without a reverse t3, I'm very underwhelmed by the tsh of 12, it's not that uncommon to see in ICU pts as euthyroid sick Syndrome isn't uncommon. However, my personal approach would be to look at random ACTH, if it low, I'd emperically treat both hydrocortisone and levothyroxine until rT3 is back, just because of the frequency of hypothyroid & and hypoandrenalism is present.

It's good to have this in the back of your mind, but it ain't that common. I've only had 1, and I don't now if you were involved in the case at your IM joint, the pulm PD was bragging about having a case when I interviewed there. I've had several "textbook" presentations of old people in ED, hypothermic, bradycardia, hypotensive, altered, hypercarbic with Hyperkalemia....and they all have normal to mildly elevated tsh but turn out to be septic that respond to septic treatment alone without any levothyroxine. I got snippy with a ER resident several months back as they presented that to me on the phone and I wondered out loud if this was the case and the ***** replied the pt is only groggy, not comatose. "Really? And here I didn't realize that coma was part of the diagnostic criteria."

What's a "normal" TSH in an octogenarian anyway? Heh.

And of course thyroid is all over the place in the critically ill, but if there is a high TSH, with LOW t3/t4, and the symptoms of myxedema coma, then I'm going to treat them. The mortality from myxedema is abysmal even when it's recognized.

I don't think the patient in the OP has myxedema coma based on labs and is probably just septic gomer syndrome, but vent's asking me what I would do if I have low levels of of t3/t4 and I'm going to go with a working dx of myxedema probably secondary to sepsis and I'm going to treat that patient if I have serious suspicion of myxedema with appropriate labs.

 

[Hernandez]

And of course thyroid is all over the place in the critically ill, but if there is a high TSH, with LOW t3/t4, and the symptoms of myxedema coma, then I'm going to treat them. The mortality from myxedema is abysmal even when it's recognized..

This I have no disagreement with.

 

[jdh71]

This I have no disagreement with.

And we are the only guys appropriately worried about the adrenals in this guy too

Vent get's only half points for his AM cortisol

 

[Hernandez]

And we are the only guys appropriately worried about the adrenals in this guy too

Vent get's only half points for his AM cortisol

Yup yup. Normally I wouldn't bother checking without a history suggestive of adrenal insuf (namely lots of steroids, or h/o Addison's) but with the thyroid being wonky and hypothermia and other board buzz words, I'd get a random. Then to back to bed

 

[VentdependenT]

I run into this thyroid $hit in these situations all the time. Just seeing what you would do.

Is giving a critically ill pt with crappy t3 to t4 conversion benign?

I am NOT arguing against jdh

 

[VentdependenT]

And we are the only guys appropriately worried about the adrenals in this guy too

Vent get's only half points for his AM cortisol

I want all the points damn it!!!

 

[Hernandez]

I run into this thyroid $hit in these situations all the time. Just seeing what you would do.

Is giving a critically ill pt with crappy t3 to t4 conversion benign?

All I remember off had, is in myxedema coma, giving t3 may increase mortality, I'm not aware of data suggesting 1-2 doses of levothyroxine for ESS increasing mortality. I dunno about y'all, but a rT3 takes a day or so at my joint.

 

[jdh71]

I run into this thyroid $hit in these situations all the time. Just seeing what you would do.

Is giving a critically ill pt with crappy t3 to t4 conversion benign?

I am NOT arguing against jdh

It might not be benign in 80 year old coronaries - give it slowly and carefully if you're going to

 

[jdh71]

All I remember off had, is in myxedema coma, giving t3 may increase mortality, I'm not aware of data suggesting 1-2 doses of levothyroxine for ESS increasing mortality. I dunno about y'all, but a rT3 takes a day or so at my joint.

Isn't the reverse really only helpful if you're dealing with a CENTRAL hypothyroid anyway?

I think the bottom line is to simply NOT draw a single thyroid lab UNLESS you are actually suspicious of REAL thyroid disease.

 

[VentdependenT]

Ok tackled thyroid. Boston enlighten us about septic gomer.

 

[Hernandez]

Isn't the reverse really only helpful if you're dealing with a CENTRAL hypothyroid anyway?

I think the bottom line is to simply NOT draw a single thyroid lab UNLESS you are actually suspicious of REAL thyroid disease.

W/o a history of ablation or antecedent thyroditis, wouldn't primary hypothyroidism seem unlikely. Hopefully this guy hasn't been the victim of an attempted assassination by ortho and his medicine team by forgetting to resume his levothyroxine if he has primary hypothyroidism. That's we're a review of previous medical records is handy

 

[VentdependenT]

ortho assasinations are my favorite

 

[jdh71]

ortho assasinations are my favorite

Well . . . to be fair . . . we've allowed them to get away with this bad behavior so long because they brought so much money to the hospital that it can't be fixed

It's sad too. Some of the smartest kids go onto become useless as physicians outside of their very, narrow scope of primary practice.

 

[Bostonredsox]

Sorry guys busy couple of days.

So. What I did

Tube
Line
My bedside echo showed good LV but collapsible RV and IVC. Volume down to me.
Ct chest from Ed had bibasilar PNA.
I drew random. Cortisol...19
He does have levoT 100mcg on his home med list for hypoT. Unsure about compliance
I gave Iv levoT, stress dose hydrocortisone
Vanc/zosyn
Started with dopamine given bradycardia.
I voted for switch to levophed, dopamine was quickly maxed, and isuprel for chronotrop. + vaso if still below map goal.
Attending added Levo to dopa, no chronotrop/ionotrope
Grabbed scvo2 58. I advocated for iono given picture of myxedema + septic shock.
Attending agreed stop dopa, Levo/dobut add in vaso.
Warmed saline + bear hugger
Temp improved, hr improved, had pacer pads on through the night.
Lactate was 2.7

Following morning hemodynamics are improved.
UOP 100ml in 18 hours.
Creat up to 4 from 3.2, baseline is 1.9
K+ was normal now 6.1
I skipped the nephro consult and went right to transfer for cvvhd
Accepted and out the door 45 min later.

Accepting intensivist actually said I assume you are the intensivist given the succinct and quick presentation and description of therapy/hemodynamic stabilization....made me blush as I said no. He said good job kid you'll make a good intensivist, but ps this guys gonna die if you don't already know that. Yes sir I know this. Ok so we're all good, chopper en route.

So basically my dx was myxedema coma + septic shock 2/2 PNA + presumed adrenal insufficiency

Some pst case reading.....there is no correlation with severity of myxedema to the tsh level. Hern is correct though, I should have gotten a reverse t3.

Nice job all.

 

[VentdependenT]

Holy crap I didnt know they still made isoproterinol.

Anyways thanks for the case and info about tsh levels

 

[Bostonredsox]

Yeah Isuprel is rarely indicated for most pts but if you have decent squeeze just need more chronicity for CO it's a pure beta agonist. Does the trick.

 

[glorfindel]

Some pst case reading.....there is no correlation with severity of myxedema to the tsh level. Hern is correct though, I should have gotten a reverse t3.

Good case! Good learning points! Thx.

 

[jdh71]

Had a thought on the case - check the blood pressure and Sv02 in the context of the lactate.

I wonder if being in a low metabolic state could bring those variables at a bit of variance.

Something to keep in the back of my mind I think.

 

[VentdependenT]

Had a thought on the case - check the blood pressure and Sv02 in the context of the lactate.

I wonder if being in a low metabolic state could bring those variables at a bit of variance.

Something to keep in the back of my mind I think.

And 100k later he's back in the nursing home with dialysis MWF!

Wonder how much a chopper ride with EMT crew runs? make that 150k later

 

[Hernandez]

Helo's are cheaper on weekdays....not as much demand for st elsewhere transfers mon-thurs

 

[Dwindlin]

And 100k later he's back in the nursing home with dialysis MWF!

Wonder how much a chopper ride with EMT crew runs? make that 150k later

Average is probably 8k base plus patient loaded miles (this can vary quite a bit). Average total charge for our service here is around 15k.

 

[VentdependenT]

Average is probably 8k base plus patient loaded miles (this can vary quite a bit). Average total charge for our service here is around 15k.

Not as bad as I thought! thats for everything from fuel to paying the crew? its a great service and there must be an average of 10 landings a day at UL but Ive never asked the crew about how much it costs. Conditions were never approriate for that discussion

 

[Dwindlin]

Yeah that's for everything. And we probably have higher fuel costs than most since we are one of three services in the country that flies Dauphins.


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