rohitpatel said:
I just dont beleive tsh is not needed in the emergency setting, can't just start someone on methimazole/ptu for the heck of it. even the rural hospital i worked at had TSH available on weekends...
I routinely start someone on inderal for outpt endocrine or PMD follow up pending TSH results if they are hypersympathetic and I suspect hyperthyroid. If TFT's normal, it should provide symptomatic relief anyway, provided other causes of symptoms are excluded. I don't think there is a big need to start methimazole emergently in the ED- it is an outpatient treatment, and these folks routinely get first seen in a clinic and then followed up and started on a treatment in a week or so anyway- they don't have stat TSH in the primary clinic either.
The few times I have wanted a stat TSH was for a possible myxedema coma where I wanted to start IV synthroid. These were sick hypothermic, bradycardic, etc. patients. If there was a history of hypothyroidism I gave the synthroid empirically. Similar to stress steroids it probably won't hurt a patient with that constellation of physiologic symptoms even if their TSH is normal. So it is a rare case indeed where the TSH would do anything other than confirm or disprove my suspicions. However, in none of the cases was my therapy or patient care significantly changed by the result.
The B12 thing is a nonissue in my opinion. I cannot see a reason to ever need one stat in the ED- No specific antidote for toxicity. Empiric therapy is benign if low levels are suspected. No emergency indication for a stat level.
When considering the necessity of such stat tests, you must be able to argue that it will alter your patient management. While having every result imaginable available stat might make your diagnostic process easier, a large part of the art of emergency medicine is how to creatively solve these issues with a limited database. Experience makes this stuff become much easier because you learn new ways to approach the same problem. On the other hand, perhaps you could prove an improved outcome in some endpoint by performing a study looking at the availability of either of these tests stat- while it would very difficult to envision that mortality is affected, perhaps you could see a benefit in some measure of morbidity such as the cost of follow up visits, since you are making the diagnosis earlier, or improved patient satisfaction indices, which is extremely important in emergency medicine- however, there is much more exciting research to be done in the ED.
By the way, I do have a stat TSH available at one of the institutions I work in- only time I use it is when an otherwise healthy patient comes in and really wants a stat TSH done since
it takes so long to get it done in the clinic...
Good luck
P Benson
Faculty
USC+LAC
