WK4 - Lecture 16 - Adrenal Insufficiency & Crisis - Thyroid Emergencies PDF

DH 410 EMERGENCIES IN DENTAL PRACTICE LECTURE: ADRENAL INSUFFICIENCY & CRISIS & THYROID EMERGENCIES Objectives  Understand the adrenal gland function  Understand and describe etiologies of adrenal insufficiency  Recognize signs and symptoms associated with adrenal cri...

DH 410 EMERGENCIES IN DENTAL PRACTICE LECTURE: ADRENAL INSUFFICIENCY & CRISIS & THYROID EMERGENCIES Objectives  Understand the adrenal gland function  Understand and describe etiologies of adrenal insufficiency  Recognize signs and symptoms associated with adrenal crisis  Understand and prepare for treatment of patients experiencing adrenal crisis Adrenal Glands  Endocrine glands  At top of both kidneys  Consist of:  medulla (center)  cortex (surrounding area) The adrenal glands Adrenal Glands  Produce steroid hormones that control  Heart rate  Blood pressure  Metabolism  Response to stress  Blood sugar levels  More…. Adrenal Glands  Medulla  Epinephrine “adrenaline” fight-or-flight, heart rate, blood pressure  Norepinephrine Vasoconstrictor of blood vessels Adrenal Glands  Cortex  Aldosterone Control salt levels in the body  Cortisol Stresshormone Increase blood sugar, tissue repair  Androgens Male and female hormones Adrenal Insufficiency  Two categories  Primary(Addison’s disease)  Secondary  They are both CHRONIC conditions Primary Adrenal Insufficiency Primary (Addison’s Disease)  Adrenalcortex [outside portion] not producing enough hormones Respond to stress Regulate salt levels, blood pressure  Etiologies: autoimmune (approx. 70% of cases), TB, AIDS  40+ years of age, Women > Men  Clinical symptoms not usually present until 90% of both cortex have been destroyed  Secondary Adrenal Insufficiency Secondary A problem with pituitary gland Pea size structure in brain Releases ACTH (Adrenocorticotropic Hormone) Stimulates adrenal gland to make cortisol  No ACTH = no cortisol Cortisol = regulates stress, blood sugar, tissue repair  More common than primary (Addison’s Disease)  60+ years of age, Women > Men Signs & Symptoms: Adrenal Insufficiency Primary & Secondary:  Flu-like symptoms  Nausea  Fatigue  Weight Loss  Hyperpigmentation (Addison’s only) Treatment: Adrenal Insufficiency Treatment  Hormone replacement  Stabilize hormone levels  Steroid: Hydrocortisone (most common) Adrenal Crisis!!!  Body severely lacking cortisol  Life-threatening  Occurs 2 possible reasons: 1. Individual not yet diagnosed Condition often mimics other illnesses 2. Patient with adrenal insufficiency in a stressful situation and requires additional cortisol Stresssets it off Often occurs in individuals on long time steroid therapy Signs and Symptoms: Adrenal Crisis A severe cortisol deficiency that leads to:  Hypotension  Dehydration – when coupled with stress can lead to -  Tachycardia  Shock  Cardiac arrest Treatment of Adrenal Crisis  Position: supine, feet elevated (hypotensive) comfortable (non hypotensive) Emergency Management: Adrenal Crisis  Position: supine, feet elevated (hypotensive) comfortable (non hypotensive)  Lightheaded  Fatigue, weak, drowsieness  Blurry vision, dizzy  Headache  Heart palpitations, tachycardia  Confusion  Nausea Emergency Management: Adrenal Crisis  Position: supine, feet elevated (hypotensive, low BP) comfortable (non hypotensive)  Definitive Care:  Contact EMS  Monitor vital signs  Administer O2 4-6 L/ minute if needed  Administer Glucocorticosteroid (if available) DDS or medical professional only & only if the patient has a history of adrenal insufficiency Prevention: Adrenal Crisis Adrenal crisis is rare is a dental setting Risk factors include:  Ending treatment with a corticosteroid too early  Stressful situations  i.e. dental appointment  Need to consult MD Prevention: Adrenal Crisis  Regimen – most patients taking steroids do not need additional steroids for dental treatment unless severe phobic or major surgical procedure (additional 5-10 mg hydrocortisone if stressful) Reference: Low Risk of Adrenal Crisis in Dental Setting https://jada.ada.org/article/S0002-8177(14)60616-4/pdf https://dimensionsofdentalhygiene.com/article/corticosteroid-supplementation/ THYROID EMERGENCIES Objectives  State anatomical location of the thyroid  Define goiter  Differentiate between hyper- and hypothyroidism  Compare and contrast symptoms of hyper- and hypothyroidism  Determine the dental relevance for patients with hyper- and hypothyroidism  Determine suggested medical emergency management of patients experiencing an unconscious state of myxedema and thyroid strom WHERE IS IT? Thyroid Gland  Butterfly shaped organ  Anterior to trachea  Endocrine gland  Produces thyroid hormones that determine:  Metabolic rate  Growth rate  Other body mechanisms The thyroid gland Effects of thyroxine  Goiter  Nodular goiter enlarged thyroid gland with multiple nodules Inflammation of thyroid gland - NOT present in all cases “A goiter can occur in a gland that is producing too much hormone (hyperthyroidism), too little hormone (hypothyroidism), or the correct amount of hormone (euthyroidism). A goiter indicates there is a condition present which is causing the thyroid to grow abnormally” https://www.mayoclinic.org/diseases-conditions/goiter/symptoms-causes/syc-20351829  Hypothyroidism  Not enough thyroid hormone produced  SIGNS & SYMPTOMS:  Cold intolerance (wearing sweats in summer heat)  Unexplained weight gain  Mental slowing  Physical slowing  Dry skin  Hypothyroidism Etiologies:  Pituitary Tumors Pituitary gland tells thyroid what to do Not enough thyroid hormone being produced  Hoshimoto’s Thyroiditis Autoimmune disease  Surgery or Irradiation Altering gland  Treatment of Hypothyroidism  Synthetic thyroid hormone  Needto take for life  Common Drug: Levothyroxine  Hyperthyroidism  Too much thyroid hormone produced  SIGNS & SYMPTOMS:  Heat intolerance (Shorts in dead of winter)  Unexplained weight loss  Increased appetite  Nervousness, tremors  Insomnia  Rapid heart rate  Sweating  Bulging eyes/Exophalmos  Hyperthyroidism Etiologies:  Graves’ Disease Originunknown Hereditary Autoimmune suspected  Not all Hyperthyroidism is due to Graves’ disease Graves Disease  Unknown Etiology  Marty Feldman (actor) Treatment of Hyperthyroidism  3 methods –  Anti-thyroid medications Several available – methimazole or propylthiouracil Temporary treatment – common relapse  Ablation therapy (decrease thyroid function) Radioactive iodine to disable thyroid gland  Surgery Removal of thyroid gland Last resort; complications  Dental Considerations: Hypothyroidism  Most are asymptomatic and managed by physician  Medical consult consideration  Caution with CNS depressants (anti-anxiety drugs)  Dental appointment can be managed normally  Dental Considerations: Hyperthyroidism  Most managed by physician  Dental appointment can be managed normally  Review cardiac findings  Higher prevalence for cardiovascular disease risk  May appear nervous or anxious (hard to differentiate)  Anxious: cold, clammy palms  Hyperthryroidism: warm, sweaty palms Thyroid Emergencies  Myxedema coma (hypo) Loss of brain function as a result of severe, longstanding low level of thyroid hormone in the blood  Thyroid storm (hyper) Results from untreated hyperthyroidism. Usually brought on by a stress, such as trauma or infection. Myxedema Coma  Usually patient NOT comatose – misnomer  Myxedema – hard, nonpitting edema  Occurs when body unable to compensate for severe thyroid hormone deficiency  End point of chronic hypothyroidism  Etiologies: undiagnosed hypothyroidism, incorrect treatment, trauma, infection, surgery, medications  More common 70+ years, >women  Signs and Symptoms: Myxedema Coma  Hallucinations  Hypothermia (