HHNKTHYROID DISORDERS

Dr. Miada Mahmoud Rady

EMS /474

HHNK

HHNK

HHNK : Hyperosmolar Hyperglycemic Non Ketotic

Syndrome.

Also known as ; HONK : Hyperosmolar Non Ketotic

Syndrome.

It is life threatening complication of hyperglycemia .

Commonly seen in elderly type 2 diabetics .

Develops slowly over days .

Pathophysiology

Hallmark of HHNK is marked Hyperglycemia , patient RBG is

usually more than 600mg/dl .

Marked hyperglycemia caused Increased Blood Osmolarity

which causes Osmotic Diuresis (polyuria).

Marked polyuria causes Sever Dehydration And Electrolyte

Imbalance (most prominently Hypernatremia ).

Hyperglycemia in HHNK can be either due to insulin deficiency

due to increased requirement or inappropriate action due to

increased counter regulatory hormones.

Pathophysiology

Patient with HHNK has no or very minimal ketosis……???

Because the amount of insulin present however small is

sufficient to prevent fatty acid metabolism but not sufficient to

prevent hyperglycemia .

Predisposing factors

1. Missed insulin .

2. Heavy meal .

3. Acute pancreatitis.

4. Infection .

5. Trauma .

6. Surgery .

7. MI .

8. Pregnancy.

Decreased insulin reserve

Increased insulin requirement

Clinical Tip

• For HHNK to occur the patient should be unable to

compensate marked water loss caused by hyperglycemia to

produce hyperosmolarity (which is major criteria of HHNK)

i.e. the should be unable to drink

• That is why HHNK is common in elderly ( they have an

impaired thirst sensation , unable to serve them selves ) , and

in young it is seen if the patient ability to reach water is

impaired as by intubation , anesthesia , NPO protocol .

Criteria of HHNK

1. Hyperglycemia ( marked dehydration ).

2. Hyperosmolarity ( increased serum osmolarity i.e. sodium

concentration ).

3. Marked dehydration.

4. Absent or very minimal ketosis.

5. No acidosis.

Clinical Presentation of HHNK

1.Slow progression of symptoms over days.

2.Dehydration( warm flushed skin , dry tongue , and mucous

membranes)

3.Polyuria followed by Oliguria late.

4.Prominent neurological features as :

Drowsiness

Focal or generalized seizures

Hemiparesis and Sensory deficits

Patient slowly passes into coma.

Laboratory Finding

1. Hyperglycemia : more 600mg/dl.

2. Hypernatremia : increased serum sodium.

3. No or very minimal ketosis.

4. No ketonuria .

Management

Follow the general guidelines for patient care :

1. Airway :

Top priority

Manage and maintain patent airway as indicated

If the patient is comatosed protect airway , be ware of vomiting

and have suction ready .

Advanced airway and ETT may be needed

2. Breathing :

Maintain adequate oxygenation.

3. Circulation :

Record and continuously monitor cardiac rhythm and

vital signs.

Obtain serial 12 lead ECG .

Measure blood glucose level .

Start an I.V line and Give 12.5 – 25 gm of 50% dextrose

if blood glucose level is below 70 mg/dl or cannot be

determined.

Management

Management

Start normal saline per local protocols :

1. Give 500 ml normal saline over 30 minutes as bolus.

2. In patients with a history of congestive heart failure

and/or renal insufficiency, a 250-mL bolus may be more

appropriate.

3. Patients may receive 1 to 2 L within the first hour.

Management

3. Transport patient rapidly .

4. Continuously reassess patient (A,B and C).

MMR

ThyroidGland

disorders

Thyroid Control

• Thyroid gland secretes thyroid hormone in response to

stimulation from anterior pituitary by thyroid stimulating

hormone ( TSH ) , which is released in response to stimulation

of anterior pituitary by thyroid releasing (TRH) by

hypothalamus .

• Thyroid hormones in turn inhibit the anterior pituitary

secretion of TSH and hypothalamus secretion of TRH.

Hypothalamo-pituitary Thyroid

Axis.

Thyroid gland disorders

Result from either Increased or decreased thyroid

hormone production:

1. Increased thyroid hormone production is called

hyperthyroidism.

2. Decreased thyroid hormone production is called

hypothyroidism.

Hyperthyroidism and Thyrotoxicosis

Hyperthyroidism : increased level of circulating thyroid

hormone ,( laboratory finding).

Thyrotoxicosis : toxic syndrome resulting from increased

level of circulating thyroid hormone , (clinical term ).

Myxoedema: clinical syndrome resulting from decreased

level of circulating thyroid hormone below normal.

Clinical Presentation of Thyrotoxicosis

1. Irritability , nervousness.

2. Insomnia .

3. Weight loss.

4. Excessive sweating .

5. Intolerance to hot weather.

6. Tachycardia .

7. Thyrotoxic heart failure.

8. Dyspnea .

9. Diarrhea .

10. Menstrual irregularities .

11. Hand tremers.

Special Types of Hyperthyroidism

1. Graves disease :

Most common form of hyperthyroidism.

More common females .

Autoimmune disorder .

It is sever and may be fatal if untreated.

In addition to the common symptoms of Thyrotoxicosis , it

has 3 characteristic finding:

Graves disease

1. Exophthalmos : forward protrusion of the rye

ball .

2. Pretibial Myxoedema : non pitting edema of

the skin on the anterior part of the leg below the

knee.

3. Goiter : diffuse enlargement of the thyroid

gland.

Exophthalmos and goiter

Exophthalmos and goiter

Hashimoto disease

More common in females .

It is an autoimmune disorder caused by production of auto

antibodies against TSH receptors on thyroid follicles causing

first over hyperthyroidism and Thyrotoxicosis , followed by

destruction of TSH receptors causing hypothyroidism .

So the patient first present with Thyrotoxicosis followed by

hypothyroidism.

Clinical Presentation Hypothyroidism

1. Slow cerebration and depression .

2. Excessive sleeping .

3. Weight gain.

4. Intolerance to cold weather .

5. Dry skin.

6. Bradycardia .

7. Hypertension and IHD.

8. Menstrual irregularities .

9. Constipation .

THYROID EMERGENCIES

Thyroid Storm

Definition : rare life threatening exacerbation of manifestation

of thyrotoxicosis .

Predisposing factors :

1. Stress .

2. Operation.

3. Trauma .

4. Infection.

Clinical presentation

1. High grade fever (hyperpyrexia).

2. Severe tachycardia , arrhythmias and heart failure .

3. Nausea .

4. Vomiting .

5. Dehydration.

6. Convulsions , hallucinations and altered mental status.

Management of Thyroid Storm

Mainly supportive care :

1. Ensure patent air way .

2. Maintain adequate oxygenation and ventilation.

3. Continuously assess vital signs .

4. Lower body temperature by cold fomentation , cooling.

5. Phenobarbital is given for convulsion.

6. Rapid transport.

Myxoedema Coma

Definition : rare life threatening complication of untreated

hypothyroidism accompanied by physiological decomposition.

It is seen in long standing untreated cases of hypothyroidism.

More common in elderly females especially during winter.

If not diagnosed and treated immediately, the mortality rates are

approximately 50%.

Predisposing factors

1. Infection (especially pulmonary and urinary tract).

2. Exposure to cold.

3. Trauma.

4. Surgery.

5. Certain medications e.g. those used to treat advanced cases of

diabetic neuropathy pregablin .

Clinical presentation

1. Hallmark is Deterioration Of Mental Status ( old , obese

female who become lethargic , sleepy and easily slips to

coma).

2. Hypothermia even in presence of infection.

3. Hypoventilation and hypoxia.

4. Symptoms of hypothyroidism .

Management

1. Airway and breathing :

a. Administer supplemental oxygen therapy to

correct hypoxia.

b. Intubation and ventilation may be indicated.

2. Circulation :

a. Continuously monitor the patient’s cardiac

rhythm and blood pressure.

b. In case of hypotension crystalloids are

given .

c. Persistent hypotension vasopressors are

given.

d. Administer 25 to 50 g of D50 if glucose

levels are less than 60 mg/dL.

3. Hypothermia treatment :

First try passive rewarming.

Active rewarming is done for hemodynamically

unstable patients with profound hypothermia.

Avoid aggressive rewarming may lead to

vasodilatation and hypotension.

4. Rapidly transport the patient .

Any questions?