1 00:00:00,489 --> 00:00:04,994 The patient has no prior history of a thyroid condition, so there's no 2 00:00:04,994 --> 00:00:07,364 way they have a thyroid emergency. 3 00:00:07,864 --> 00:00:10,670 Sam thyroid disease is like black mold in Florida. 4 00:00:10,670 --> 00:00:13,348 It's out there and if, you just happen to wait around long 5 00:00:13,348 --> 00:00:14,708 enough, it'll show up on things 6 00:00:16,464 --> 00:00:19,504 Hi everyone, and welcome back to another episode of EMplify. 7 00:00:19,524 --> 00:00:23,004 I'm your host, Sam Ashoo, and before we jump into this month's 8 00:00:23,004 --> 00:00:29,964 episode, I want to celebrate with you because EB Medicine is 26 years old. 9 00:00:30,014 --> 00:00:34,514 For 26 years we've been kicking it with emergency medicine, CME, and 10 00:00:34,514 --> 00:00:39,464 now urgent care, CME, providing you education and courses, and to 11 00:00:39,464 --> 00:00:46,654 celebrate this month, you get 26% off all purchases at ebmedicine.net. 12 00:00:46,874 --> 00:00:49,304 So go there now, become a subscriber. 13 00:00:49,304 --> 00:00:54,404 Take advantage of this tremendous discount and get all of your CME needs met. 14 00:00:54,404 --> 00:00:56,768 And while you're there, you'll see the NEW! 15 00:00:56,798 --> 00:01:01,055 laceration course, the abscess course, the EKG course, the Coding 16 00:01:01,085 --> 00:01:05,315 and Billing course, the DEA Mate course, and fill all of your CME needs 17 00:01:05,315 --> 00:01:07,385 for whatever state you practice in. 18 00:01:07,441 --> 00:01:08,971 It's just a fantastic deal. 19 00:01:09,211 --> 00:01:11,221 Go there today, become a subscriber. 20 00:01:11,821 --> 00:01:13,981 And now let's jump into our monthly episode. 21 00:01:14,748 --> 00:01:19,098 Hello, ladies and gentlemen, and welcome back to another episode of Amplify. 22 00:01:19,098 --> 00:01:21,358 I am one of your hosts, Sam Ashoo. 23 00:01:21,378 --> 00:01:23,718 In on the other end of the microphone is 24 00:01:24,307 --> 00:01:29,402 Dr. TR Eckler back again, but much more afraid of the thyroid 25 00:01:29,672 --> 00:01:31,522 than I was just a few hours 26 00:01:31,673 --> 00:01:32,853 no doubt. 27 00:01:33,503 --> 00:01:35,838 Today we are talking about the. 28 00:01:36,009 --> 00:01:41,019 June, 2025, emergency Medicine Practice article on the emergency 29 00:01:41,019 --> 00:01:44,259 department management of patients with thyroid emergencies. 30 00:01:44,509 --> 00:01:47,869 This is Dr. Shaw and Dr. Chang who authored this article, and it is 31 00:01:48,079 --> 00:01:51,509 tremendous as always, but a little scary. 32 00:01:51,539 --> 00:01:56,759 I will say, my common practice for thyroid emergencies has apparently 33 00:01:56,789 --> 00:01:59,279 not been aggressive enough. 34 00:01:59,504 --> 00:02:04,584 According to most of what I read today, which is disappointing and scary. 35 00:02:05,061 --> 00:02:05,931 what are your thoughts on that? 36 00:02:05,987 --> 00:02:09,857 did you have the same appreciation for thyroid disease as you do now? 37 00:02:10,357 --> 00:02:14,077 First, I wanna just note that this is a supremely timely article. 38 00:02:14,077 --> 00:02:17,987 I think we're coming into pretty scary hot American summer, with a 39 00:02:17,987 --> 00:02:22,637 lot of big storms chances for people to be without power in severe heat. 40 00:02:22,727 --> 00:02:26,897 And my biggest takeaway was, you know, thyroid storm happens in the summer 41 00:02:26,942 --> 00:02:29,162 and, decompensated hypothyroidism, or. 42 00:02:29,327 --> 00:02:32,337 Mixed edema, coma, whatever you wanna call it at this point, happens 43 00:02:32,337 --> 00:02:33,627 much more often in the winter. 44 00:02:33,807 --> 00:02:36,567 So it seems to me that this is something I need to raise my 45 00:02:36,867 --> 00:02:41,307 alertness about seasonally and also like related to around disasters and 46 00:02:41,307 --> 00:02:42,777 power losses and things like that. 47 00:02:43,137 --> 00:02:46,317 But also, would agree with you, I think I left this article with a much 48 00:02:46,317 --> 00:02:48,147 clearer sense of how to manage it. 49 00:02:48,477 --> 00:02:53,757 And a much greater fear that it's really challenging to make this diagnosis. 50 00:02:53,847 --> 00:02:57,927 And you have to have a high alert, and you always wanna be, even if 51 00:02:57,927 --> 00:03:01,107 you're not sure, you're wanting to pitch this to your admitting team and 52 00:03:01,107 --> 00:03:04,467 say, I think that this is where this is headed and therefore I think we 53 00:03:04,467 --> 00:03:05,847 should go this way with treatment. 54 00:03:05,847 --> 00:03:06,117 What do you 55 00:03:06,998 --> 00:03:07,208 Yeah. 56 00:03:07,208 --> 00:03:09,818 that's a, that's a great point and a great summary. 57 00:03:09,818 --> 00:03:10,058 Really. 58 00:03:10,058 --> 00:03:14,468 This article is on the polar extremes of thyroid disease. 59 00:03:14,468 --> 00:03:18,938 We're talking about decompensated hypothyroidism, PS that used to be 60 00:03:18,938 --> 00:03:23,078 called mixed edema coma, and I was unaware of the terminology change. 61 00:03:23,258 --> 00:03:24,248 It just makes me old. 62 00:03:24,428 --> 00:03:27,858 So, decompensated hypothyroidism is now. 63 00:03:27,993 --> 00:03:32,563 The correct term, which is a pretty rare condition usually found in the elderly. 64 00:03:32,563 --> 00:03:35,623 You know, more prevalent in Women Peak, somewhere like in between 65 00:03:35,623 --> 00:03:40,643 ages 60 and 85, and like you said is more common in the winter months. 66 00:03:40,763 --> 00:03:43,463 So up to 90% of those presentations are in the winter. 67 00:03:43,793 --> 00:03:44,093 And then. 68 00:03:44,743 --> 00:03:50,143 On the polar extreme opposite is the thyroid storm. 69 00:03:50,143 --> 00:03:55,813 So that's the most extreme version of hyperthyroidism or thyroid toxicosis, 70 00:03:56,093 --> 00:04:00,393 which generally presents or peaks in the summer months, is more rare. 71 00:04:00,588 --> 00:04:03,618 So we're talking like, you know, four to five people per a hundred thousand, 72 00:04:03,958 --> 00:04:08,338 in hospitalized patients, and even more rare than that in the general population. 73 00:04:08,558 --> 00:04:13,388 But just as alarmingly worrisome when it comes to their presentation in the ed, 74 00:04:13,388 --> 00:04:17,621 I. And I would say that the one thing I took away from this article that was the 75 00:04:17,621 --> 00:04:23,111 most alarming was how many other things mimic these conditions or how many other 76 00:04:23,111 --> 00:04:25,901 things can complicate these conditions. 77 00:04:26,211 --> 00:04:28,731 The differential diagnosis there is quite long. 78 00:04:28,731 --> 00:04:32,061 Table two is fantastic in the article, but you know, decompensated, 79 00:04:32,061 --> 00:04:36,631 hypothyroidism, the differential for it is everything from acute. 80 00:04:37,213 --> 00:04:41,863 Mi to carbon monoxide poisoning to encephalopathies and hypercarbia, 81 00:04:41,923 --> 00:04:45,343 and then all of the derangement that come from the disease. 82 00:04:45,343 --> 00:04:48,893 Things like hypoglycemia, hypothermia, altered mental status. 83 00:04:48,963 --> 00:04:51,963 And then there's the mimics as well, like sepsis and stroke. 84 00:04:51,963 --> 00:04:55,533 And so it can confound so many diseases. 85 00:04:55,533 --> 00:04:59,463 It can be associated with so many diseases, and it has its own presenting 86 00:04:59,613 --> 00:05:05,013 symptoms, It seems like if you've got someone who's not at their normal baseline 87 00:05:05,013 --> 00:05:09,303 for any reason, you should be checking a TSH on them, just as routine practice, 88 00:05:09,423 --> 00:05:11,133 if they're in the geriatric population, 89 00:05:11,617 --> 00:05:15,292 A hundred percent and also cardiac patients, and I feel better that I've 90 00:05:15,292 --> 00:05:19,762 been doing that a lot in my practice and I felt like I was starting to wonder if 91 00:05:19,762 --> 00:05:24,202 maybe I too aggressive and now I feel pretty confident that I'm fishing in the 92 00:05:24,202 --> 00:05:28,522 right ponds for the right kind of fish that I need to worry about having bad 93 00:05:28,773 --> 00:05:29,193 Yeah, 94 00:05:29,482 --> 00:05:33,442 Can I have a brief, just 10 seconds for a history of 95 00:05:33,442 --> 00:05:35,662 medicine appreciation mixed edema 96 00:05:36,278 --> 00:05:38,258 The history of medicine by TR Eckler. 97 00:05:38,798 --> 00:05:41,345 history of medicine, corner, mixed edema, coma. 98 00:05:41,435 --> 00:05:45,725 The mixed edema comes from Greek meaning mucus and swelling. 99 00:05:46,460 --> 00:05:50,600 Because it's referring to the deposition of mucopolysaccharides that would 100 00:05:50,600 --> 00:05:54,680 go into your dermis when you develop mixed edema coma, which is why you 101 00:05:54,680 --> 00:05:58,070 get non-pitting edema these patients. 102 00:05:58,220 --> 00:06:01,310 So if you notice that they're having edema, if it's not pitting, you need 103 00:06:01,310 --> 00:06:04,130 to worry that this is more mixed edema coma, because they're depositing 104 00:06:04,250 --> 00:06:06,020 mucopolysaccharides in their dermis. 105 00:06:06,140 --> 00:06:11,870 First treated successfully in 1891 by a British gentleman 106 00:06:11,870 --> 00:06:13,460 named George Red, Maine Murray. 107 00:06:14,150 --> 00:06:17,420 diagnosed a 46-year-old lady with the disease and treated her with 108 00:06:17,420 --> 00:06:21,320 sheep thyroid extract, successfully managing it for another 28 109 00:06:21,451 --> 00:06:21,901 Wow. 110 00:06:22,591 --> 00:06:23,341 That's pretty cool. 111 00:06:23,971 --> 00:06:25,021 And there it is, ladies and gentlemen. 112 00:06:25,231 --> 00:06:26,191 The History of Medicine 113 00:06:26,270 --> 00:06:27,740 out a little history for mixed edema, 114 00:06:28,226 --> 00:06:28,616 That's good. 115 00:06:28,616 --> 00:06:29,726 That's actually very helpful. 116 00:06:29,826 --> 00:06:33,156 Yeah, the, the word mixed edema has always been kind of a. quandary to 117 00:06:33,156 --> 00:06:35,706 me, but that helps very much and kind of fits with the symptoms. 118 00:06:35,706 --> 00:06:36,336 It makes sense. 119 00:06:36,966 --> 00:06:37,446 Swelling, 120 00:06:37,570 --> 00:06:38,200 Mucus swelling. 121 00:06:38,271 --> 00:06:38,904 non-pitting. 122 00:06:38,904 --> 00:06:39,354 Excellent. 123 00:06:39,631 --> 00:06:44,161 When it comes to those decompensated hypothyroidism patients, we mentioned 124 00:06:44,161 --> 00:06:49,511 earlier, the older population, like 60 to 85 more prevalent in women, and 125 00:06:49,601 --> 00:06:54,431 in patients who are poorly controlled on their thyroid supplements. 126 00:06:54,431 --> 00:06:58,781 So even if they have a known history of thyroid disease, you should 127 00:06:58,781 --> 00:07:02,921 especially be concerned about those patients because stuff happens and 128 00:07:02,921 --> 00:07:04,001 they stop taking their medication. 129 00:07:04,324 --> 00:07:05,259 They run outta money. 130 00:07:05,259 --> 00:07:06,309 They run outta medication. 131 00:07:06,309 --> 00:07:07,449 They can't get to the pharmacy. 132 00:07:08,255 --> 00:07:15,722 And then on the other polar extreme is the thyroid storm patients 133 00:07:15,722 --> 00:07:17,522 and their differential diagnosis. 134 00:07:17,787 --> 00:07:19,437 Is equally as broad. 135 00:07:19,437 --> 00:07:23,727 So again, in that table, two things like drug withdrawal from opioids, 136 00:07:23,727 --> 00:07:28,077 alcohol and benzodiazepines, especially in this population, which actually 137 00:07:28,077 --> 00:07:30,537 happens to be a younger population. 138 00:07:30,537 --> 00:07:33,357 We're talking about people in their forties where this is generally 139 00:07:33,357 --> 00:07:36,067 presenting, things like heat stroke because they're gonna be 140 00:07:36,067 --> 00:07:39,427 hyperthermic and altered hypertensive emergencies because they're gonna 141 00:07:39,427 --> 00:07:43,397 be tachycardic and hypertensive, hypoxia, psychiatric disease, 142 00:07:43,397 --> 00:07:46,010 anxiety, panic attacks, and psychosis. 143 00:07:46,335 --> 00:07:49,755 Interestingly, it's in the differential, but all of those can 144 00:07:49,755 --> 00:07:51,795 be caused by thyroid toxicosis. 145 00:07:51,795 --> 00:07:56,175 So really, if, if this is present, you're gonna go get those thyroid studies. 146 00:07:56,385 --> 00:08:00,242 And then sepsis and tachycardias and dysrhythmias and atrial fibrillation, 147 00:08:00,242 --> 00:08:02,012 all of that stuff is in the differential. 148 00:08:02,222 --> 00:08:09,402 But again, it's concomitant to disease and it can be causal so your thyroid toxicosis 149 00:08:09,402 --> 00:08:14,532 can cause all of these things, or all of these things can alter your thyroid 150 00:08:14,532 --> 00:08:18,972 metabolism and push you over into thyroid toxicosis and give you the thyroid storm. 151 00:08:19,472 --> 00:08:24,422 And I will add that all of this talk is because of the significant 152 00:08:24,422 --> 00:08:28,622 mortality of these diseases, which was also surprising for me. 153 00:08:28,622 --> 00:08:33,612 So the decompensated hypothyroidism has a mortality of 26 to 50%, 154 00:08:33,882 --> 00:08:37,252 especially in those higher risk patients, especially if they have 155 00:08:37,342 --> 00:08:41,002 cardiac complications or hypothermia or need mechanical ventilation, 156 00:08:41,002 --> 00:08:42,982 their mortality is terribly high. 157 00:08:43,342 --> 00:08:46,552 And then on the thyroid storm side. 158 00:08:46,892 --> 00:08:52,082 They have a mortality up to 25%, which also increases the more 159 00:08:52,202 --> 00:08:55,532 organs are involved and the more the central nervous system is involved. 160 00:08:55,532 --> 00:09:01,742 So just such high mortality around these cases that it underscores the need to 161 00:09:01,892 --> 00:09:03,812 make a diagnosis and make it early. 162 00:09:04,312 --> 00:09:08,782 And I think as we're getting into this, making that diagnosis is challenging. 163 00:09:08,992 --> 00:09:12,862 And it's something that it seems like every, you know, decade, a 164 00:09:12,862 --> 00:09:15,892 new organization really tries to take a stab at trying to figure 165 00:09:15,892 --> 00:09:19,102 out what should be the diagnostic criteria, how do you define this? 166 00:09:19,132 --> 00:09:22,462 And it's not something where anyone's had a lot of success yet, so. 167 00:09:22,975 --> 00:09:24,145 Yeah, that's a great point. 168 00:09:24,195 --> 00:09:28,185 And Table One nicely summarizes all of those guidelines dating 169 00:09:28,185 --> 00:09:32,055 all the way back to 2011 from organizations like the American 170 00:09:32,055 --> 00:09:34,655 Thyroid Association and the American. 171 00:09:34,758 --> 00:09:39,528 Task force for thyroid hormone replacement and the Japanese Thyroid Association 172 00:09:39,528 --> 00:09:42,408 means so many different organizations and so many different guidelines. 173 00:09:42,588 --> 00:09:45,798 Again, the authors did a great job of trying to synthesize 174 00:09:45,798 --> 00:09:47,178 all of that in this article. 175 00:09:47,748 --> 00:09:51,605 When it comes to the pre-hospital evaluation, pre-hospital 176 00:09:51,605 --> 00:09:53,855 side is pretty much the same. 177 00:09:53,885 --> 00:09:58,655 It is, identify the vital sign abnormalities, begin some kind 178 00:09:58,655 --> 00:10:01,302 of Stabilization treatment en route to the hospital. 179 00:10:01,512 --> 00:10:05,022 And if you can, I would think the most important part, if you can get 180 00:10:05,022 --> 00:10:07,872 the history that they're supposed to be on medication, like their thyroid 181 00:10:07,872 --> 00:10:11,832 supplement and they haven't been taking it, that is just tremendously helpful. 182 00:10:12,832 --> 00:10:15,692 I. Then once they get to the ed, well then we begin our history. 183 00:10:15,752 --> 00:10:19,922 And again, the polar extremes are gonna involve the same questions. 184 00:10:19,922 --> 00:10:23,612 So for the hypothyroid patient, we're gonna ask, you know, are you fatigued? 185 00:10:23,612 --> 00:10:25,172 Have you had progressive lethargy? 186 00:10:25,172 --> 00:10:27,992 Has there been weight gain or constipation or cold intolerance? 187 00:10:28,292 --> 00:10:31,562 In the severe cases, is there a history maybe from a family member you're 188 00:10:31,562 --> 00:10:33,902 gonna get about mental status changes? 189 00:10:34,002 --> 00:10:35,022 Hypothermia? 190 00:10:35,052 --> 00:10:37,812 Has there been recent triggers like infection, trauma, stroke. 191 00:10:37,837 --> 00:10:41,137 Heart failure, GI bleeding, or recent surgery, all of those are 192 00:10:41,137 --> 00:10:45,067 triggers to push somebody into decompensated hypothyroidism. 193 00:10:45,567 --> 00:10:50,010 And on the polar opposite side of that spectrum, thyroid storm, 194 00:10:50,170 --> 00:10:53,050 is gonna present really with a patient who's quite agitated. 195 00:10:53,200 --> 00:10:56,320 So you might get the history from family in this case, about increasing 196 00:10:56,320 --> 00:10:58,180 agitation, palpitations, and tremors. 197 00:10:58,370 --> 00:11:02,070 Maybe fever at home, maybe weight loss, heat intolerance. 198 00:11:02,260 --> 00:11:05,470 And then the same triggers we're looking for anything that might 199 00:11:05,470 --> 00:11:08,870 have pushed them over the edge, like infection, trauma, stroke, heart 200 00:11:08,885 --> 00:11:10,790 failure, GI bleeding, or recent surgery. 201 00:11:11,253 --> 00:11:14,973 I found the medications to be really instructive in this area. 202 00:11:15,213 --> 00:11:18,433 I found that talking about lithium and amiodarone, I felt like I 203 00:11:18,433 --> 00:11:20,083 had a sense of those in my head. 204 00:11:20,383 --> 00:11:24,683 But talking about some of the new or chemotherapy agents, pembrolizumab, 205 00:11:25,103 --> 00:11:29,063 which I didn't know the name of from the generic, but that's Keytruda. 206 00:11:29,453 --> 00:11:31,913 Which I see cancer patients on all the time. 207 00:11:32,213 --> 00:11:36,533 And then nivolumab, which is Opdivo, which is also something 208 00:11:36,533 --> 00:11:37,883 that I'm seeing more and more of. 209 00:11:38,123 --> 00:11:43,163 So that gave me some pause to consider this more in my cancer patients that are 210 00:11:43,163 --> 00:11:44,723 coming in that are fatigued and weak. 211 00:11:44,783 --> 00:11:47,993 And I think often we attribute that to their chemo or infection, but I'm 212 00:11:47,993 --> 00:11:51,413 now gonna start thinking more about it possibly being their thyroid IV 213 00:11:51,593 --> 00:11:56,663 contrast can induce either hypo or hyper, I don't think I had quite. 214 00:11:57,032 --> 00:11:58,442 been as worried about as I should 215 00:11:58,498 --> 00:12:01,198 one more reason to be a hater of Ivy Contrast, right. 216 00:12:02,198 --> 00:12:03,578 and a hundred percent agreed. 217 00:12:03,668 --> 00:12:07,538 And then when you turn the page to thyroid storm, looking at anesthetics 218 00:12:07,538 --> 00:12:11,558 and aspirin, there's so much, you know, outpatient surgery and things that you've 219 00:12:11,558 --> 00:12:14,768 gotta then think, wait, how did they do the sedation for that outpatient surgery? 220 00:12:14,768 --> 00:12:16,058 What medicines could they have gotten? 221 00:12:16,313 --> 00:12:20,303 And then looking at aspirin, there's so much use of different aspirin. 222 00:12:21,893 --> 00:12:26,483 And BC powder and, and, just some of the wintergreen patches that people 223 00:12:26,483 --> 00:12:27,923 use for pain control these days. 224 00:12:27,923 --> 00:12:31,313 It's just another thing that I'm gonna be a little more suspicious of and a 225 00:12:31,313 --> 00:12:34,283 little more likely to get thyroid testing and kind of pursue that a bit further. 226 00:12:34,399 --> 00:12:34,849 Yeah. 227 00:12:34,909 --> 00:12:35,719 Yeah, great point. 228 00:12:35,719 --> 00:12:38,209 And honestly, in an altered patient, you know, you, you might get 229 00:12:38,209 --> 00:12:40,939 levels anyway for some of these substances, but you don't know. 230 00:12:40,939 --> 00:12:42,289 You just don't know what they're taking. 231 00:12:42,289 --> 00:12:43,519 They don't know what they're taking. 232 00:12:43,519 --> 00:12:47,059 Half the time, my own family members tell me they're taking Tylenol. 233 00:12:47,059 --> 00:12:50,824 They're taking, you know ibuprofen instead, or they're taking some aspirin 234 00:12:50,824 --> 00:12:52,264 containing product over the counter. 235 00:12:52,354 --> 00:12:53,374 They have no idea. 236 00:12:53,374 --> 00:12:54,514 They go, oh yeah, it's Tylenol. 237 00:12:54,514 --> 00:12:55,024 Like, oh, okay. 238 00:12:55,264 --> 00:12:56,794 Is it, acetaminophen on the bottle? 239 00:12:56,794 --> 00:12:58,054 Oh, no, no, no. 240 00:12:58,054 --> 00:12:59,154 It's, ibuprofen. 241 00:12:59,154 --> 00:13:01,134 And I'm like, that's, that's not Tylenol. 242 00:13:01,884 --> 00:13:02,244 So, 243 00:13:02,843 --> 00:13:05,608 I, I always like nod and then I ask 'em to send me pictures. 244 00:13:05,608 --> 00:13:06,328 I'm like, is there anybody 245 00:13:06,414 --> 00:13:07,284 yes, 246 00:13:07,318 --> 00:13:09,628 there anybody that could like, just take some pictures of your medicine 247 00:13:09,628 --> 00:13:11,008 bottles in case EMS hasn't already 248 00:13:11,034 --> 00:13:11,934 yes. 249 00:13:12,028 --> 00:13:13,828 of times they do tend to bring the medicines with them, 250 00:13:13,828 --> 00:13:15,358 which I, I find super helpful. 251 00:13:15,358 --> 00:13:18,148 But if it's always one of those things where if you can show me 252 00:13:18,148 --> 00:13:21,268 that or show me what your medicines are, or now if I can get it from 253 00:13:21,268 --> 00:13:25,288 the pharmacy records, it makes a big difference to be like, what about that? 254 00:13:25,479 --> 00:13:26,079 Yeah. 255 00:13:26,559 --> 00:13:26,769 Yeah. 256 00:13:26,769 --> 00:13:27,069 Really. 257 00:13:27,069 --> 00:13:30,789 And you know, if you walk into a cabin full of medicines and pull out the phone, 258 00:13:30,909 --> 00:13:34,209 you're the, the friendly paramedic, just take a quick snapshot of it and show 259 00:13:34,209 --> 00:13:37,989 it to us when you get to the er, you know, or stick it into chat GPT and go 260 00:13:37,989 --> 00:13:42,189 identify all the medications in this photo and just get a list and go, oh, okay. 261 00:13:42,189 --> 00:13:43,434 You know, I, I. That 262 00:13:43,813 --> 00:13:44,143 There we are. 263 00:13:44,274 --> 00:13:45,114 Oil of Wintergreen. 264 00:13:45,204 --> 00:13:45,564 Who knew? 265 00:13:46,234 --> 00:13:48,994 So yes, lots and lots of triggers and medications. 266 00:13:48,994 --> 00:13:49,804 A very important one. 267 00:13:49,804 --> 00:13:52,474 And Amiodarone really is not your friend in this scenario. 268 00:13:52,474 --> 00:13:56,314 It can cause either one of these, on the spectrum and, indefinitely. 269 00:13:56,589 --> 00:13:58,149 I. Aspirin, who knew aspirin? 270 00:13:58,689 --> 00:14:00,459 And then physical examination. 271 00:14:00,549 --> 00:14:03,819 When we're talking about the decompensated hypothyroidism, 272 00:14:03,819 --> 00:14:07,269 we're talking about things like bradycardia, hypotension, hypothermia, 273 00:14:07,335 --> 00:14:12,612 hypoventilation, slow respirations, or braa, lethargy, confusion. 274 00:14:12,677 --> 00:14:15,167 Status epilepticus, which is interesting. 275 00:14:15,167 --> 00:14:19,727 That's not one I had associated with the decompensated hypothyroidism before. 276 00:14:20,067 --> 00:14:25,167 And things like, delayed deep tendon reflexes, cool skin non-pitting 277 00:14:25,167 --> 00:14:28,887 edema, as we heard earlier in the tr ular historical corner. 278 00:14:29,107 --> 00:14:31,117 And slowed speech with some ataxia. 279 00:14:31,117 --> 00:14:31,417 Really? 280 00:14:31,417 --> 00:14:34,122 So in your, in your geriatric patient, you think they might 281 00:14:34,122 --> 00:14:35,122 have Parkinson's or something. 282 00:14:35,122 --> 00:14:37,657 They actually have decompensated hypothyroidism. 283 00:14:38,064 --> 00:14:41,214 I always think in physical exam, I try to look for pacemakers, I 284 00:14:41,214 --> 00:14:42,744 try to look for surgical scars. 285 00:14:42,954 --> 00:14:46,554 I think a neck surgical scar that suggests their thyroid is missing is 286 00:14:46,554 --> 00:14:48,144 just a really great thing to notice. 287 00:14:48,144 --> 00:14:49,704 'cause even if they say, I don't have problems with my 288 00:14:49,704 --> 00:14:51,387 thyroid, you can be like, what's 289 00:14:51,503 --> 00:14:51,983 Yeah. 290 00:14:52,047 --> 00:14:54,027 they can be oh, well there was a nodule or something. 291 00:14:54,027 --> 00:14:54,912 So they took something out. 292 00:14:54,912 --> 00:14:55,577 It's oh, 293 00:14:55,693 --> 00:14:59,403 Yeah, yeah, that's some Sherlock Holmes, level physical examination 294 00:14:59,403 --> 00:15:00,153 right there where you go. 295 00:15:00,153 --> 00:15:04,203 Ah, I see you're presenting altered in status epilepticus with a history 296 00:15:04,203 --> 00:15:07,003 of, having increasing weakness in lethargy at home, and you have a 297 00:15:07,003 --> 00:15:08,533 scar across the bottom of your neck. 298 00:15:08,533 --> 00:15:11,503 I have diagnosed you with decompensated hypothyroidism. 299 00:15:11,577 --> 00:15:14,967 Unfortunately, I missed the sepsis and forgot to start you on antibiotics. 300 00:15:15,967 --> 00:15:16,207 Right. 301 00:15:16,207 --> 00:15:20,053 So don't forget the concomitant diseases and then examination 302 00:15:20,053 --> 00:15:23,653 findings with thyroid storm, are gonna be things like fever, tachycardia, 303 00:15:23,893 --> 00:15:28,283 dysrhythmias, like atrial fibrillation, hypertension, hyperreflexia, goiters. 304 00:15:28,313 --> 00:15:31,283 So if you're looking at the neck and there is no scar, but they have a goiter, 305 00:15:31,533 --> 00:15:35,403 gastrointestinal complaints, nausea, vomiting, diarrhea, stomach cramps, 306 00:15:35,493 --> 00:15:38,983 jaundice, and proximal muscle weakness. 307 00:15:38,983 --> 00:15:43,053 So in the, in the very, extreme cases, you might see any one of those 308 00:15:43,053 --> 00:15:45,063 findings on physical examination. 309 00:15:45,563 --> 00:15:47,693 I always feel like I notice the exophthalmos like 310 00:15:47,749 --> 00:15:48,439 Oh yeah. 311 00:15:48,679 --> 00:15:49,039 Yeah. 312 00:15:49,283 --> 00:15:52,073 Like that's always the one that that kind of tends to jump out at me and, 313 00:15:52,253 --> 00:15:56,003 and help me not, you know, forget to order the Ts h but now that I'm ordering 314 00:15:56,003 --> 00:15:59,843 TSH on anybody that's a little confused or a little anxious or a little sick 315 00:15:59,843 --> 00:16:02,603 looking, I'm feeling better about making sure I've got all the levels I 316 00:16:02,734 --> 00:16:03,484 Yes, yes. 317 00:16:03,484 --> 00:16:05,764 And if you're listening to this and you're not familiar with that term, 318 00:16:05,764 --> 00:16:09,094 exophthalmos, that is, where , their eyes just appear so big that their eyelids 319 00:16:09,094 --> 00:16:10,624 can't even close all the way over them. 320 00:16:10,784 --> 00:16:13,904 It's a startling examination finding, associated really with 321 00:16:13,904 --> 00:16:17,204 hyperthyroidism, but definitely should be present in these kinds of cases. 322 00:16:17,704 --> 00:16:19,234 And then we're moving on to. 323 00:16:19,774 --> 00:16:21,034 Laboratory analysis. 324 00:16:21,034 --> 00:16:25,054 So you have some history, you have a suspicion, and that's really the crux. 325 00:16:25,054 --> 00:16:28,954 If you take away anything from this article, it is, you should have a 326 00:16:28,954 --> 00:16:33,574 healthy suspicion for both of these disease processes in someone who is 327 00:16:33,664 --> 00:16:37,054 at risk by age or by a recent history. 328 00:16:37,294 --> 00:16:41,194 And so if you can just even get to that point, the laboratory portion of 329 00:16:41,194 --> 00:16:43,084 this really isn't all that complicated. 330 00:16:43,511 --> 00:16:46,571 If they're on the decompensated hypothyroid spectrum, they might have 331 00:16:46,571 --> 00:16:49,931 associated hyponatremia and hypoglycemia. 332 00:16:50,181 --> 00:16:54,891 And you're still gonna send your standard labs and liver functions and electrolytes, 333 00:16:54,891 --> 00:16:59,581 but you will be adding things like A TSH, and most labs nowadays will do 334 00:16:59,581 --> 00:17:05,751 a reflexive t four, or free T four even, if the TSH comes back abnormal. 335 00:17:05,781 --> 00:17:08,811 So that's probably an order already built into your emergency 336 00:17:08,811 --> 00:17:10,461 department order catalog. 337 00:17:10,881 --> 00:17:16,341 And on the other side, with the thyrotoxicosis, you might see things 338 00:17:16,341 --> 00:17:21,451 like hypercalcemia, hyperglycemia, elevated liver enzymes that. 339 00:17:21,551 --> 00:17:24,701 May prompt you, you know, when you see jaundice on the exam, that may prompt 340 00:17:24,701 --> 00:17:26,111 you to go get those liver functions. 341 00:17:26,451 --> 00:17:29,811 And then similarly your TS, H and, and a free T four. 342 00:17:29,931 --> 00:17:35,721 Now interestingly, the authors did make the point that in the acute phase. 343 00:17:36,556 --> 00:17:42,316 Some of these thyroid hormone levels may not be helpful, especially in the 344 00:17:42,316 --> 00:17:44,926 decompensated hypothyroidism category. 345 00:17:45,166 --> 00:17:50,116 They may still appear normal and they're more a reflection of recent 346 00:17:50,116 --> 00:17:56,011 history than they are of this moment right now, which again, I have to admit 347 00:17:56,011 --> 00:17:59,581 was new to me because I'm accustomed to seeing this and going, oh, okay. 348 00:17:59,581 --> 00:18:02,341 You know, the TSH is high, your T four is low, you're hypothyroid, 349 00:18:02,581 --> 00:18:03,941 or you're critically hypothyroid. 350 00:18:03,961 --> 00:18:06,661 Your TSH is way high up in the hundreds and your T four 351 00:18:06,661 --> 00:18:08,041 is completely undetectable. 352 00:18:08,401 --> 00:18:13,351 That is not the case, which unfortunately adds a lot of gray to these cases. 353 00:18:13,351 --> 00:18:17,401 So you can have the clinical suspicion and have the history and then get the 354 00:18:17,401 --> 00:18:22,141 labs and go, oh, these labs aren't as bad as I thought, and then get completely 355 00:18:22,141 --> 00:18:24,571 distracted and not treat the patient. 356 00:18:24,781 --> 00:18:28,886 And a, the authors did a good job of dissuading that thought process and 357 00:18:28,886 --> 00:18:33,276 saying even if these labs are not as bad as you would think, especially in 358 00:18:33,276 --> 00:18:37,006 the hypothyroid patient, don't let the labs detract you from actually 359 00:18:37,006 --> 00:18:39,189 treating decompensated hypothyroidism. 360 00:18:39,439 --> 00:18:43,334 And I think to your point, when your suspicion's high, you press through, 361 00:18:43,334 --> 00:18:47,774 like you don't wait for the reflex free T four, you lead by ordering the TSH and 362 00:18:47,774 --> 00:18:51,314 the T three and the T four, so that the sooner you can, the sooner you have more 363 00:18:51,314 --> 00:18:55,894 information to then help your, admitting team, your ICU team, everybody to have 364 00:18:56,254 --> 00:19:00,034 the most information possible and then you can say, Hey, I got all those labs 365 00:19:00,034 --> 00:19:01,984 before I gave the first dose of T four. 366 00:19:02,134 --> 00:19:06,094 So those were numbers that were there before I started my treatment with that. 367 00:19:06,094 --> 00:19:08,104 Or I loaded with any steroids or anything else. 368 00:19:08,604 --> 00:19:12,864 There is a pretty good section in the beginning part of this article about 369 00:19:12,894 --> 00:19:18,294 just the physiology of thyroid disease and how it involves the hypothalamus 370 00:19:18,294 --> 00:19:21,084 and the pituitary gland, and we won't get into all that, but just know 371 00:19:21,084 --> 00:19:23,784 that if someone has severe adrenal. 372 00:19:23,814 --> 00:19:30,174 Insufficiency or pituitary gland disease, all of those can be also causes of thyroid 373 00:19:30,174 --> 00:19:32,004 disease and this kind of presentation. 374 00:19:32,004 --> 00:19:35,334 So you're gonna broaden your laboratory testing a little bit. 375 00:19:35,494 --> 00:19:40,414 Random cortisol levels are recommended to test for adrenal insufficiency in patients 376 00:19:40,414 --> 00:19:43,109 who have decompensated hypothyroidism. 377 00:19:43,299 --> 00:19:46,119 When we get down into treatment, we'll talk about giving an initial dose of 378 00:19:46,119 --> 00:19:47,859 steroids to these patients anyway. 379 00:19:47,859 --> 00:19:50,869 And so, it's definitely in the differential, arterial blood 380 00:19:50,869 --> 00:19:54,919 gas measurements, looking for hypercarbia testing for hypoxemia. 381 00:19:54,919 --> 00:19:57,803 If there's a concern or your finger saturation monitors not picking up, you're 382 00:19:57,803 --> 00:19:59,333 gonna want something more dependable. 383 00:19:59,403 --> 00:20:01,478 And then keeping that testing broad. 384 00:20:01,508 --> 00:20:03,338 So sepsis is in the differential. 385 00:20:03,338 --> 00:20:05,718 You're gonna get your cultures, you're gonna get your, lactic 386 00:20:05,718 --> 00:20:09,038 acid, and if they're presenting with altered mental status, you're 387 00:20:09,038 --> 00:20:10,598 gonna get your scan of the brain. 388 00:20:10,878 --> 00:20:12,858 You're gonna consider things like lumbar puncture and 389 00:20:12,858 --> 00:20:14,278 meningitis in your differential. 390 00:20:14,414 --> 00:20:17,564 and then for cardiac testing, like you mentioned, especially in your MI 391 00:20:17,564 --> 00:20:21,344 patients or if they have dysrhythmias or EKG findings, you're going troponins 392 00:20:21,344 --> 00:20:23,114 and go down that route as well. 393 00:20:23,294 --> 00:20:28,154 So it's a big blanket of laboratory testing we're looking at. 394 00:20:28,854 --> 00:20:33,321 And the same with the hyperthyroid or the thyroid toxic patients, 395 00:20:33,488 --> 00:20:34,868 they're at risk for the same thing. 396 00:20:34,868 --> 00:20:39,108 So you're looking at EKG telemetry, you're getting all of those labs in the ABG. 397 00:20:39,128 --> 00:20:41,888 You're looking for things like metabolic acidosis that is associated 398 00:20:41,888 --> 00:20:43,598 with this, looking for triggers. 399 00:20:44,228 --> 00:20:48,158 Interestingly, there is this Burch-Wartofsky score. 400 00:20:48,218 --> 00:20:49,478 You ever used that before? 401 00:20:49,908 --> 00:20:53,568 I haven't, but I think I would be more interested in it as selling it to. 402 00:20:54,003 --> 00:20:57,693 This is the reason we need to go to the ICU because our score is so high 403 00:20:57,693 --> 00:20:59,223 on the, I like their abbreviation. 404 00:20:59,223 --> 00:21:00,123 The BWPS 405 00:21:00,134 --> 00:21:00,346 Yeah 406 00:21:00,346 --> 00:21:02,116 good short acronym for your score. 407 00:21:02,116 --> 00:21:03,106 It sounds serious. 408 00:21:03,480 --> 00:21:06,570 it's available in MD Calc, so if you're user, just go look up 409 00:21:06,570 --> 00:21:08,610 BWPS or type in hyperthyroidism. 410 00:21:08,610 --> 00:21:14,244 But it's a scoring system that gives you a number for thyroid storm, and that number 411 00:21:14,244 --> 00:21:17,247 correlates to, classifying their risk. 412 00:21:17,367 --> 00:21:21,657 And so if their number is above a certain cut point, which is 45 or 413 00:21:21,807 --> 00:21:24,787 higher, that's consistent with thyroid storm and those people are at high 414 00:21:24,787 --> 00:21:29,257 risk and therefore need that more intensive monitoring, if it's not already 415 00:21:29,257 --> 00:21:33,457 obvious from their presentation, you can use that as a little bit of extra 416 00:21:33,457 --> 00:21:36,037 push to help justify the diagnosis. 417 00:21:36,117 --> 00:21:41,577 Table five is a great breakdown of what to expect from your TSH free, T 418 00:21:41,577 --> 00:21:47,097 four in total, T three in the different states of thyroid disease being 419 00:21:47,127 --> 00:21:49,587 normal, all the way to hypo and hyper. 420 00:21:49,587 --> 00:21:50,847 And we don't have to get into all that. 421 00:21:50,847 --> 00:21:54,027 Just know that it's a reference and you can look that up if 422 00:21:54,027 --> 00:21:55,047 there's a question about it. 423 00:21:55,294 --> 00:21:58,930 if it's not obvious from looking at the labs, then that 424 00:21:58,930 --> 00:22:00,040 will help you interpret that. 425 00:22:00,740 --> 00:22:02,330 And then we get into treatment. 426 00:22:02,510 --> 00:22:06,140 So treatment depends on which side of the spectrum they're on. 427 00:22:06,270 --> 00:22:10,410 Certainly both of these categories of patients are going to the ICU. 428 00:22:10,470 --> 00:22:16,110 Your decompensated hypothyroidism and your thyroid storm are both critical patients. 429 00:22:16,320 --> 00:22:17,820 They're all going to the ICU. 430 00:22:18,339 --> 00:22:22,479 I really liked their introduction to this, like looking at stabilization 431 00:22:22,479 --> 00:22:25,209 and treatment as, when you look at these patients, you need to think 432 00:22:25,209 --> 00:22:28,179 about oxygenation, ventilation, and perfusion because this is a 433 00:22:28,179 --> 00:22:31,959 disease that affects their entire body, not just their hormone levels. 434 00:22:32,229 --> 00:22:33,939 And I found it to be really. 435 00:22:34,289 --> 00:22:38,659 humbling how much I needed to consider the whole picture and really think about 436 00:22:38,659 --> 00:22:43,129 their ABCs and what I was gonna need to do to try to stabilize them from 437 00:22:43,129 --> 00:22:47,869 an overall systemic standpoint while I was managing their endocrine emergency. 438 00:22:48,255 --> 00:22:48,495 Yeah. 439 00:22:49,125 --> 00:22:49,965 Yeah, that's a great point. 440 00:22:50,025 --> 00:22:53,475 So, you know, the basics count and you have to support 441 00:22:53,685 --> 00:22:55,095 all of their organ systems. 442 00:22:55,095 --> 00:22:55,875 That's excellent. 443 00:22:56,111 --> 00:23:02,396 When it gets down to targeted therapy for your decompensated hypothyroidism patient. 444 00:23:02,546 --> 00:23:03,716 You've got some options. 445 00:23:03,746 --> 00:23:07,316 Obviously if they can take something orally, you can start replacing thyroid 446 00:23:07,316 --> 00:23:10,166 that way, but IV replacement is available. 447 00:23:10,316 --> 00:23:13,376 Most places have IVT four available. 448 00:23:13,660 --> 00:23:18,850 there is an interesting distinction there between IV T four and IVT three. 449 00:23:19,166 --> 00:23:23,696 The T four gets converted to T three in the body and you can give IVT three. 450 00:23:24,256 --> 00:23:25,456 But there is some question there. 451 00:23:25,456 --> 00:23:27,766 I thought the authors did a good job of discussing this as well. 452 00:23:27,790 --> 00:23:31,030 there is some question about whether or not that comes with a 453 00:23:31,030 --> 00:23:33,100 higher incidence of side effects. 454 00:23:33,130 --> 00:23:35,830 You know, things like dysrhythmias and other abnormalities. 455 00:23:36,090 --> 00:23:38,970 and the dosing is a little bit sketchy. 456 00:23:39,096 --> 00:23:42,006 and so you gotta be a little careful not to accidentally give somebody too much. 457 00:23:42,345 --> 00:23:45,225 there seems to be a suggestion in the literature that it might be safer 458 00:23:45,225 --> 00:23:46,905 to just give somebody Iiv T four. 459 00:23:47,055 --> 00:23:50,475 And that's probably honestly what you have available in the pharmacy anyway. 460 00:23:50,775 --> 00:23:53,155 So, the dosing there is pretty simple. 461 00:23:53,155 --> 00:23:55,975 A loading dose of two to 400 micrograms and then a maintenance 462 00:23:55,975 --> 00:23:57,685 dose of 50 to a hundred daily. 463 00:23:57,755 --> 00:24:00,335 and you're just gonna give that one time in the emergency department 464 00:24:00,335 --> 00:24:03,815 to, you know, standard adult dose, start at 200 micrograms and work your 465 00:24:03,815 --> 00:24:05,075 way up, especially in the elderly. 466 00:24:05,575 --> 00:24:09,100 Give the T four ask endocrinology if they want to give the T three. 467 00:24:09,581 --> 00:24:09,921 There you go. 468 00:24:10,311 --> 00:24:10,671 Great. 469 00:24:10,671 --> 00:24:14,147 If you have endocrinology available to you, that's a great person 470 00:24:14,207 --> 00:24:15,857 to call early in this process. 471 00:24:16,287 --> 00:24:19,227 Or if you're out in the rural places, that's a good consult to ask because 472 00:24:19,227 --> 00:24:24,057 you can often stabilize these patients out in the rural places with that 473 00:24:24,057 --> 00:24:27,027 first dose of medicine, and then you can see how they respond to it. 474 00:24:27,207 --> 00:24:30,297 And if you can get the endocrinologist on the phone to help guide that treatment 475 00:24:30,507 --> 00:24:34,497 and escalate treatment if needed to be, I think that's enormously valuable for that 476 00:24:34,497 --> 00:24:38,307 patient that isn't necessarily sitting on the, you know, the doorstep of a tertiary 477 00:24:38,307 --> 00:24:39,897 academic center down the road from 'em. 478 00:24:39,908 --> 00:24:41,138 Yeah, yeah, great point. 479 00:24:41,638 --> 00:24:43,108 And then steroids. 480 00:24:43,108 --> 00:24:46,138 So again, for the decompensated hypothyroid patient, we 481 00:24:46,138 --> 00:24:47,485 do give dose steroids. 482 00:24:47,485 --> 00:24:51,665 We're talking about a hundred milligram IV load of hydrocortisone, followed 483 00:24:51,665 --> 00:24:53,675 by 50 milligrams IV every eight hours. 484 00:24:53,675 --> 00:24:56,465 And hopefully they're long gone out of your ED at that point. 485 00:24:56,805 --> 00:25:00,565 But if not, that's something that needs to be continued, because of that 486 00:25:00,565 --> 00:25:02,785 association with adrenal insufficiency. 487 00:25:02,865 --> 00:25:03,975 This will combat that. 488 00:25:03,975 --> 00:25:05,355 It will help with hypotension. 489 00:25:05,505 --> 00:25:08,535 If they're sick enough to require pressors, it'll hopefully help with 490 00:25:08,535 --> 00:25:10,185 their response to pressors as well. 491 00:25:10,435 --> 00:25:16,795 Interestingly, if they have decompensated hypothyroidism and you provide IV 492 00:25:17,185 --> 00:25:21,565 T four to somebody who's in shock without giving them the steroids, you 493 00:25:21,565 --> 00:25:23,365 can actually clinically worsen them. 494 00:25:23,645 --> 00:25:25,855 So it's something to keep in the back of your mind. 495 00:25:25,855 --> 00:25:28,825 Those two things should be going together in this critical population. 496 00:25:29,325 --> 00:25:31,330 With the antibiotics. 497 00:25:31,491 --> 00:25:32,181 absolutely. 498 00:25:32,301 --> 00:25:32,811 That's right. 499 00:25:32,901 --> 00:25:34,461 You're gonna be treating that septic shock. 500 00:25:34,611 --> 00:25:39,181 You can certainly reach for pressors if they're in shock, but just know that they 501 00:25:39,181 --> 00:25:41,611 also need the T four and the steroids. 502 00:25:41,641 --> 00:25:44,641 So this is not to supplant the need for pressors. 503 00:25:45,641 --> 00:25:51,701 And then on again, the polar opposite side for the thyrotoxic thyroid storm 504 00:25:51,791 --> 00:25:55,091 patients, this gets a little bit more complicated just 'cause we have 505 00:25:55,091 --> 00:25:57,161 multiple categories of medicines, right? 506 00:25:57,371 --> 00:26:03,191 So we need something to block the symptoms that tachy, dysrhythmia and hypertension. 507 00:26:03,491 --> 00:26:07,731 We need something to block new hormone synthesis. 508 00:26:07,941 --> 00:26:12,231 We need something to block existing hormone from being released. 509 00:26:12,441 --> 00:26:16,191 And then we need something to reduce the conversion of any hormone 510 00:26:16,191 --> 00:26:18,531 that's in their serum into T three. 511 00:26:18,711 --> 00:26:23,751 So all four of those things are four different categories to 512 00:26:23,751 --> 00:26:25,581 block the tacky dysrhythmias. 513 00:26:25,581 --> 00:26:27,201 We're looking at beta blockers. 514 00:26:27,411 --> 00:26:32,161 Propranolol is still the preferential treatment, and it can be given down in ng. 515 00:26:32,461 --> 00:26:36,349 So if you don't have it iv, you can give it orally, or you can give it enterically. 516 00:26:36,569 --> 00:26:39,479 If the person's unable to take oral, put an NG down and give it that way. 517 00:26:40,019 --> 00:26:44,459 Or another option instead of IV propranolol, which I would say a lot 518 00:26:44,459 --> 00:26:48,949 of us probably don't have available to us, is IV esmolol, titrable 519 00:26:49,609 --> 00:26:52,139 quickly on, quickly off, as needed. 520 00:26:52,139 --> 00:26:56,129 If they end up having hypotension or some complication, that is certainly an option. 521 00:26:56,129 --> 00:26:58,409 And this patient is going to go to the ICU anyway. 522 00:26:58,439 --> 00:27:00,389 So just one more infusion. 523 00:27:01,389 --> 00:27:06,069 And then blocking new hormone synthesis is your PTU, your 524 00:27:06,319 --> 00:27:08,759 propothyouricil, and your methimazole. 525 00:27:08,909 --> 00:27:11,184 And propothyouricil is the preferred agent. 526 00:27:11,184 --> 00:27:13,974 It's also the only one approved to give to a pregnant patient. 527 00:27:13,974 --> 00:27:17,264 So if you've got someone who's thyrotoxic, in thyroid storm and 528 00:27:17,264 --> 00:27:22,214 pregnant, this is the medication of choice also given orally and. 529 00:27:22,614 --> 00:27:27,024 Then to block the release of hormone that's already made and 530 00:27:27,024 --> 00:27:30,144 sitting in the thyroid gland, you're gonna give the iodine. 531 00:27:30,144 --> 00:27:33,714 That's the saturated solution of potassium iodide or the SSKI. 532 00:27:34,214 --> 00:27:39,314 With the stipulation that that's given after you've already given somebody PTU. 533 00:27:39,584 --> 00:27:43,364 So you gotta wait , about an hour after you've given somebody the 534 00:27:43,364 --> 00:27:46,334 medicine to block new hormone synthesis before you go, giving them a giant 535 00:27:46,334 --> 00:27:50,904 dose of iodide, because that will block the release of the new hormone. 536 00:27:50,904 --> 00:27:53,784 But if you haven't given them the PTU, it'll just result in 537 00:27:53,784 --> 00:27:55,254 them making more thyroid hormone. 538 00:27:56,254 --> 00:28:02,524 And then lastly, to reduce the conversion of T four to T three in the serum or in 539 00:28:02,524 --> 00:28:05,608 the peripheral organs, corticosteroids. 540 00:28:05,728 --> 00:28:07,168 So you've heard that already. 541 00:28:07,228 --> 00:28:10,828 We've already given that to the patient who was decompensated hypothyroidism. 542 00:28:10,828 --> 00:28:13,858 We're also gonna give it to the patient with the thyrotoxic disease. 543 00:28:14,258 --> 00:28:17,798 So that's four different medicines we're giving to the thyroid storm, 544 00:28:17,798 --> 00:28:22,188 the beta blockers, the ides, which is the PTU, the iodine solution. 545 00:28:22,578 --> 00:28:26,638 And the steroid, hopefully in the right order, but this table does a good job. 546 00:28:26,638 --> 00:28:30,248 Table seven on page 11 of kinda walking you through that process. 547 00:28:30,498 --> 00:28:34,008 Definitely wanna follow some kind of guideline to remember how much 548 00:28:34,008 --> 00:28:37,368 and in what order to give all this in in the thyroid storm patient. 549 00:28:38,368 --> 00:28:41,668 Significantly higher dose of steroids in the thyroid storm. 550 00:28:41,668 --> 00:28:45,478 You're looking at 300 milligrams of hydrocortisone versus only a hundred 551 00:28:45,478 --> 00:28:49,818 milligrams for your patient that's got decompensated hypothyroidism. 552 00:28:49,998 --> 00:28:53,298 So I think this is a good thing to basically have your plan, know what 553 00:28:53,298 --> 00:28:56,748 you're gonna do, you know, start yourself on this treatment plan, but then at 554 00:28:56,748 --> 00:28:59,508 that point you also call endocrinology and say, Hey, this is where I'm going. 555 00:28:59,778 --> 00:29:01,548 Anything else you wanna add or subtract? 556 00:29:01,698 --> 00:29:03,528 Especially if they know the patient, I think that's always a 557 00:29:03,528 --> 00:29:04,848 great time to get them involved. 558 00:29:05,399 --> 00:29:06,914 Yeah, great points there. 559 00:29:07,114 --> 00:29:11,464 Rationale for the higher dose is because in, the thyroid storm patient, 560 00:29:11,869 --> 00:29:15,199 you are trying to prevent that peripheral conversion of T four to T 561 00:29:15,199 --> 00:29:16,999 three, which requires more steroids. 562 00:29:17,179 --> 00:29:20,059 We're not giving this for adrenal insufficiency, which is 563 00:29:20,299 --> 00:29:21,709 traditionally a lower dosing. 564 00:29:22,039 --> 00:29:22,789 So yes. 565 00:29:22,819 --> 00:29:24,229 Excellent, excellent point there. 566 00:29:24,799 --> 00:29:25,369 Aspirin. 567 00:29:25,369 --> 00:29:29,029 We talked about aspirin already, but obviously if they're on aspirin or 568 00:29:29,029 --> 00:29:32,509 if stroke is in the differential, if you're entertaining this diagnosis, 569 00:29:32,509 --> 00:29:36,589 aspirin containing products can actually make things worse and can 570 00:29:36,589 --> 00:29:40,799 lead to displacement of thyroid hormone binding, and increase the serum levels. 571 00:29:40,799 --> 00:29:45,139 So kind of judicious use there, you're gonna have multiple specialties 572 00:29:45,139 --> 00:29:48,169 involved if you're entertaining a stroke as a possibility. 573 00:29:48,409 --> 00:29:52,549 And so making that diagnosis more accurately becomes important because 574 00:29:52,819 --> 00:29:56,059 you, you may end up accidentally worsening their condition by 575 00:29:56,059 --> 00:29:59,749 administering something like aspirin, which again, just underscores the 576 00:29:59,749 --> 00:30:01,634 complexity of making this diagnosis. 577 00:30:02,134 --> 00:30:05,224 Interestingly, you know, patients who fail medical therapy for 578 00:30:05,224 --> 00:30:11,104 thyroid storm are going on to pretty significant labor intensive treatment. 579 00:30:11,104 --> 00:30:14,804 We're talking about things like urgent thyroidectomy, or plasma 580 00:30:14,954 --> 00:30:19,004 pheresis, which has been helpful in, as a bridge to thyroidectomy 581 00:30:19,004 --> 00:30:25,179 for patients to kind of, sift the serum for t four and catecholamines 582 00:30:25,179 --> 00:30:27,639 and autoantibodies and toxins. 583 00:30:27,769 --> 00:30:31,369 So there are benefits to plasmapherisis, but obviously that's labor intensive 584 00:30:31,369 --> 00:30:33,079 as well, and hopefully done in the ICU. 585 00:30:33,419 --> 00:30:37,015 So those are kind of second, third line therapies beyond the medical, 586 00:30:37,015 --> 00:30:38,365 if the medical is still not working. 587 00:30:39,146 --> 00:30:43,443 so looking at special circumstances and populations, think the biggest thing 588 00:30:43,443 --> 00:30:47,763 I took away from this was the airway considerations you have in these patients. 589 00:30:49,156 --> 00:30:53,446 patients that might have mixed edema of their tongue, their posterior pharynx. 590 00:30:53,626 --> 00:30:56,776 They can have compression of their trachea and their airway because of 591 00:30:56,776 --> 00:31:00,436 a goiter or because of a thyroid mass or something else that's in that area. 592 00:31:00,766 --> 00:31:04,486 So I think that treating these airways as high risk from both a 593 00:31:04,576 --> 00:31:08,596 structural standpoint and possibly also from a physiologic standpoint. 594 00:31:08,896 --> 00:31:12,796 These people can be hard to ventilate, they can be difficult to intubate, 595 00:31:12,886 --> 00:31:16,216 and they basically are not gonna breathe as well leading up to it. 596 00:31:16,596 --> 00:31:21,159 So you have to really be more fearful of and more cautious in making sure 597 00:31:21,309 --> 00:31:24,399 that you preoxygenate and that you're addressing their hypercapnea and 598 00:31:24,399 --> 00:31:28,389 you're reaching for BiPAP and other ventilator strategies earlier in order 599 00:31:28,389 --> 00:31:31,659 to support them while you're figuring out what you can do to stabilize them. 600 00:31:31,869 --> 00:31:35,019 But I think you need to approach this airway with an appropriate amount of 601 00:31:35,374 --> 00:31:38,764 wanting to load the boat and making sure that if you're thinking you need 602 00:31:38,764 --> 00:31:43,234 intubate, that anesthesia or ENT are there because it's not something that you want 603 00:31:43,234 --> 00:31:46,804 to try to do in the ER by yourself to perform a crike on a patient with a large 604 00:31:47,085 --> 00:31:48,915 Hmm, yes. 605 00:31:49,575 --> 00:31:52,515 I don't wanna have to do a crike anyway, but I can't think of anything 606 00:31:52,515 --> 00:31:55,845 more terrifying than having to do a crike on someone with a giant goiter 607 00:31:55,845 --> 00:31:57,315 exactly where I'm going to be cutting. 608 00:31:57,585 --> 00:31:59,805 That's just going to make things so much more difficult. 609 00:31:59,805 --> 00:32:00,495 So yes. 610 00:32:00,885 --> 00:32:04,545 Excellent, . And definitely something to be aware of in advance. 611 00:32:05,025 --> 00:32:06,405 Risk management pitfalls. 612 00:32:06,405 --> 00:32:08,505 This was a very helpful section to me. 613 00:32:08,555 --> 00:32:11,705 Not that it usually isn't, but I thought this really highlighted some things. 614 00:32:11,705 --> 00:32:13,407 So I'm just gonna ask some of these questions. 615 00:32:13,407 --> 00:32:17,217 Like the lab said that the thyroid studies won't be back for another 616 00:32:17,217 --> 00:32:21,667 hour, so I waited for those results to start treatment Oh. 617 00:32:21,771 --> 00:32:24,711 if, if it was only gonna be an hour, that sounds great to me in modern 618 00:32:24,711 --> 00:32:28,461 emergency medicine, Sam, because let me tell you, the pharmacy ain't getting 619 00:32:28,461 --> 00:32:30,111 that medicine there in one hour. 620 00:32:30,201 --> 00:32:35,481 If I need some IVT four and IVT three, but I would tell you that I think. 621 00:32:35,691 --> 00:32:40,341 As soon as you have suspicion for this, and as soon as you can confirm that 622 00:32:40,341 --> 00:32:44,451 either the patient's got a history of higher low thyroid and your suspicion's 623 00:32:44,451 --> 00:32:47,991 there, I'm trying to initiate treatment as soon as I can without necessarily 624 00:32:47,991 --> 00:32:52,041 waiting for the labs, but I think that that's always such a moving spectrum. 625 00:32:52,161 --> 00:32:54,681 You're just trying to do the best you can and get as much information as you 626 00:32:54,681 --> 00:32:56,557 can and move the ball as quickly as you 627 00:32:56,588 --> 00:32:57,188 Perfect. 628 00:32:57,278 --> 00:33:00,098 And you know, practically speaking, if you know it's gonna be another hour before 629 00:33:00,098 --> 00:33:03,158 the lab comes back and you know it's gonna be an hour before the pharmacy gets 630 00:33:03,158 --> 00:33:06,548 you the medicine, just order it now and then if you don't use it, send it back. 631 00:33:06,938 --> 00:33:07,148 I mean, 632 00:33:07,158 --> 00:33:09,108 I get TPA out of the Pyxis all the time. 633 00:33:09,258 --> 00:33:11,178 I don't use it very much, but I like to have it 634 00:33:11,369 --> 00:33:11,669 Yeah. 635 00:33:11,819 --> 00:33:12,059 Yeah. 636 00:33:12,909 --> 00:33:13,119 Okay. 637 00:33:13,119 --> 00:33:17,169 Her decompensated hypothyroidism is so severe, I opted for 638 00:33:17,169 --> 00:33:18,909 T three instead of T four. 639 00:33:19,459 --> 00:33:23,239 I think I would want an endocrinologist to tell me to do that because I think there's 640 00:33:23,239 --> 00:33:24,739 risks that come with that decision. 641 00:33:24,919 --> 00:33:28,789 And I think I would start with T four and then I would reach out to the 642 00:33:28,789 --> 00:33:32,659 specialists, especially as this patient's heading for the ICU and say, do you wanna 643 00:33:32,659 --> 00:33:34,249 escalate to T three or something else? 644 00:33:34,249 --> 00:33:36,349 And often they'll say, no, you've done a great job. 645 00:33:36,439 --> 00:33:37,789 Let's see what happens next. 646 00:33:37,810 --> 00:33:38,350 Exactly. 647 00:33:38,350 --> 00:33:40,420 Call me back at 10:00 AM tomorrow morning. 648 00:33:41,987 --> 00:33:42,682 I will see him in 649 00:33:42,733 --> 00:33:43,213 That's right. 650 00:33:43,613 --> 00:33:43,973 Yes. 651 00:33:43,973 --> 00:33:47,603 And that's because that T three does have this, possibility of 652 00:33:47,603 --> 00:33:49,193 increasing cardiac dysrhythmias. 653 00:33:49,253 --> 00:33:51,503 So if you're gonna give it, make sure they're on the monitor and 654 00:33:51,503 --> 00:33:53,753 you're watching closely, but preferably just give the T four. 655 00:33:54,303 --> 00:33:59,113 I gave the patient a diuretic because the chest x-ray showed pulmonary edema. 656 00:33:59,143 --> 00:34:02,833 Now this one, you're gonna get that chest x-ray result back before 657 00:34:02,833 --> 00:34:04,873 you get anything else, right? 658 00:34:04,933 --> 00:34:06,433 Before a single lab has returned. 659 00:34:06,433 --> 00:34:08,533 Maybe your blood gas or your point of care testing. 660 00:34:08,593 --> 00:34:12,073 But before you get any other piece of laboratory information, you've 661 00:34:12,073 --> 00:34:13,543 already seen the chest x-ray. 662 00:34:13,723 --> 00:34:16,693 You know the patient is hypoxic, maybe, and you're looking at 663 00:34:16,693 --> 00:34:18,193 this X-ray going, oh, it's edema. 664 00:34:18,373 --> 00:34:20,293 It's decompensated heart failure. 665 00:34:20,533 --> 00:34:23,123 They have tachypnea and tachycardia. 666 00:34:23,243 --> 00:34:24,503 Maybe they're hypertensive. 667 00:34:24,503 --> 00:34:26,093 It's a hypertensive emergency. 668 00:34:26,303 --> 00:34:27,803 I gave 'em a dose of diuretic. 669 00:34:28,013 --> 00:34:29,513 It seems reasonable. 670 00:34:30,013 --> 00:34:33,823 As you and I have previously discussed, acute decompensated heart failure 671 00:34:33,823 --> 00:34:37,603 responds better to medicine to control blood pressure like nitros and. 672 00:34:39,360 --> 00:34:41,130 BiPAP and respiratory support. 673 00:34:41,340 --> 00:34:44,260 So if that's what the chest x-ray you're looking at, you treat them with 674 00:34:44,260 --> 00:34:47,260 the, treatments that have been shown to be effective in that first hour. 675 00:34:47,350 --> 00:34:50,140 And then I think you wait to see your labs and then I think you 676 00:34:50,140 --> 00:34:51,670 wait to get more information. 677 00:34:51,730 --> 00:34:53,860 And then I think you make the diuretic choice. 678 00:34:54,040 --> 00:34:56,950 But I don't think leading with diuretics in the acute heart failure 679 00:34:56,950 --> 00:35:01,360 patient or the acute decompensated thyroid patient is the right 680 00:35:01,431 --> 00:35:01,701 Yeah. 681 00:35:01,821 --> 00:35:02,061 Yeah. 682 00:35:02,121 --> 00:35:05,781 And really the, thought process behind that is you're giving them something 683 00:35:05,781 --> 00:35:09,861 that's going to intravascularly deplete them, and this person is going to crash 684 00:35:10,041 --> 00:35:12,531 and become remarkably hypotensive. 685 00:35:12,531 --> 00:35:17,001 So even though they have pulmonary edema on the x-ray, if you wanna go ahead 686 00:35:17,001 --> 00:35:18,741 and start treating that, like you said. 687 00:35:19,111 --> 00:35:21,781 BiPAP or some kind of positive pressure ventilation. 688 00:35:22,041 --> 00:35:28,521 And judicious use of IV fluids is actually indicated in the thyroid storm patient, 689 00:35:28,761 --> 00:35:32,841 even in the presence of pulmonary edema because they're intravascularly depleted. 690 00:35:32,991 --> 00:35:35,181 A very complex scenario. 691 00:35:35,241 --> 00:35:37,661 So make sure you're placing the calls for assistance there. 692 00:35:38,381 --> 00:35:40,445 Great moment for, bedside ultrasound too. 693 00:35:40,715 --> 00:35:44,345 You look at their, IVC, you look at their heart, you look at their lungs, you see if 694 00:35:44,345 --> 00:35:49,115 it really does look like CHF, but I think you can take that one chest x-ray and use 695 00:35:49,115 --> 00:35:52,595 the next steps to get more information to help guide your treatment in a way that's 696 00:35:52,595 --> 00:35:54,245 safer and more effective for the patient. 697 00:35:55,201 --> 00:35:55,441 All right. 698 00:35:55,441 --> 00:35:55,801 Next. 699 00:35:55,801 --> 00:35:59,401 I suspected a diagnosis of decompensated hypothyroidism. 700 00:35:59,431 --> 00:35:59,971 Excellent. 701 00:36:00,396 --> 00:36:03,331 And I gave thyroid hormone replacement. 702 00:36:03,421 --> 00:36:04,111 Excellent. 703 00:36:04,681 --> 00:36:08,281 While waiting on the corticosteroids to come from the pharmacy. 704 00:36:08,707 --> 00:36:09,842 I got a problem there, Sam. 705 00:36:09,932 --> 00:36:14,432 'cause now we might precipitate more worsening of their condition by 706 00:36:14,582 --> 00:36:18,182 precipitating their adrenal crisis and making them hypotensive in a way 707 00:36:18,182 --> 00:36:19,652 that isn't gonna respond to pressors. 708 00:36:19,922 --> 00:36:22,322 So we give the triangle together. 709 00:36:22,352 --> 00:36:26,222 We suspect the sepsis, we give them the steroids, we give them the thyroid 710 00:36:26,222 --> 00:36:28,292 hormone altogether as soon as we 711 00:36:28,418 --> 00:36:29,288 Yes, yes. 712 00:36:29,288 --> 00:36:33,788 Because if their decompensated hypothyroidism is coming from adrenal 713 00:36:33,788 --> 00:36:40,238 insufficiency and you spank those adrenal glands with more thyroid medication, it 714 00:36:40,238 --> 00:36:42,338 ain't gonna do squat for this patient. 715 00:36:42,558 --> 00:36:44,058 it might actually make them worse. 716 00:36:44,118 --> 00:36:47,568 It might precipitate even worsening adrenal deficiency. 717 00:36:47,758 --> 00:36:49,738 In that case, they need the steroids. 718 00:36:49,738 --> 00:36:50,968 So steroids. 719 00:36:51,338 --> 00:36:53,468 With the T four or just before, 720 00:36:54,108 --> 00:36:59,178 , She was hypothermic, so I placed a warming blanket and gave warm IV fluids. 721 00:36:59,838 --> 00:37:00,498 Any issues with that? 722 00:37:00,998 --> 00:37:04,868 I think that warming blankets are okay, and I've learned that the bear 723 00:37:04,868 --> 00:37:09,658 hugger is always acceptable, but warm IV fluids sometimes can be a little 724 00:37:09,928 --> 00:37:12,898 too aggressive because either the patient doesn't want IV fluids or 725 00:37:12,898 --> 00:37:14,458 they don't wanna be warm that fast. 726 00:37:14,698 --> 00:37:18,268 So I would tell you to be cautious, especially in these patients with active 727 00:37:18,388 --> 00:37:19,888 rewarming as opposed to passive rewarming. 728 00:37:20,319 --> 00:37:20,649 That's right. 729 00:37:20,919 --> 00:37:21,459 That's right. 730 00:37:21,459 --> 00:37:24,279 Because passive rewarming, is a little bit slower. 731 00:37:24,279 --> 00:37:27,219 The active rewarming can actually lead to peripheral vasodilation, and if 732 00:37:27,219 --> 00:37:30,509 they're hypotensive, it can even worsen that more so just gotta be careful 733 00:37:30,509 --> 00:37:32,189 with how rapidly we're making changes. 734 00:37:32,239 --> 00:37:34,819 Does the Bear hugger also have a bear cooler setting 735 00:37:34,819 --> 00:37:35,839 as we're heading into summer? 736 00:37:36,109 --> 00:37:39,499 That's just a, I wonder if now in the age of everything, you know, like everybody 737 00:37:39,499 --> 00:37:43,189 being into ice baths, does Bear Hugger gonna roll out a Bear Hugger 2.0? 738 00:37:43,399 --> 00:37:44,269 That can become a bear 739 00:37:44,415 --> 00:37:45,135 Why not? 740 00:37:45,135 --> 00:37:45,525 I mean, the 741 00:37:45,559 --> 00:37:45,769 tool. 742 00:37:45,885 --> 00:37:49,455 ED is already like at 65 degrees just normally, right? 743 00:37:49,560 --> 00:37:50,220 So I mean. 744 00:37:50,599 --> 00:37:55,279 We are very worried about healthcare costs and very not concerned about HVAC 745 00:37:55,380 --> 00:37:55,830 That's right. 746 00:37:55,969 --> 00:37:56,809 emergency physicians 747 00:37:56,850 --> 00:37:57,210 That's right. 748 00:37:57,210 --> 00:38:00,000 I mean, I'm in there with my parca on in the trauma bay trying to 749 00:38:00,000 --> 00:38:02,760 resuscitate people, so why not, uh, 750 00:38:02,760 --> 00:38:09,030 The patient has a contraindication to beta blockers, so I have no option for rate 751 00:38:09,030 --> 00:38:11,370 control in the setting of thyroid storm. 752 00:38:11,700 --> 00:38:12,810 True or false? 753 00:38:13,810 --> 00:38:14,470 That's false. 754 00:38:14,500 --> 00:38:17,170 I got a million ways I can slow your heart down, Sam, and I would 755 00:38:17,170 --> 00:38:20,750 tell you that always think that you need to consider all your options. 756 00:38:20,930 --> 00:38:24,530 Calcium channel blockers for IL and Diltiazem can be used for 757 00:38:24,530 --> 00:38:26,000 rate control in patients like 758 00:38:26,136 --> 00:38:26,886 Perfect answer. 759 00:38:27,556 --> 00:38:32,061 The patient has no prior history of a thyroid condition, so there's no 760 00:38:32,061 --> 00:38:34,431 way they have a thyroid emergency. 761 00:38:35,431 --> 00:38:38,237 Sam thyroid disease is like black mold in Florida. 762 00:38:38,237 --> 00:38:40,915 It's out there and if, you just happen to wait around long 763 00:38:40,915 --> 00:38:42,275 enough, it'll show up on things 764 00:38:42,761 --> 00:38:43,211 Perfect. 765 00:38:43,371 --> 00:38:48,351 And lastly, she is hypothermic because it's winter and EMS said she 766 00:38:48,351 --> 00:38:50,031 didn't have the heat on in her home. 767 00:38:51,031 --> 00:38:55,141 90% of decompensated hypothyroid happens in the wintertime. 768 00:38:55,381 --> 00:39:00,341 So yes, she could be cold, but yes, she could also have myxedema 769 00:39:00,361 --> 00:39:02,641 coma now named decompensated 770 00:39:02,892 --> 00:39:06,942 Exactly, yes, she could be cold and yes, she could have 771 00:39:06,942 --> 00:39:08,382 decompensated hypothyroidism. 772 00:39:08,502 --> 00:39:12,497 So don't forget about your thyroid disease and that ladies and gentlemen. 773 00:39:12,987 --> 00:39:17,877 Brings us to the end of this June, 2025, wonderful emergency medicine 774 00:39:17,877 --> 00:39:21,787 practice review of management of patients with thyroid emergencies 775 00:39:21,877 --> 00:39:22,867 in the emergency department. 776 00:39:23,087 --> 00:39:25,457 Again, thanks to our authors, Dr. Sean, Dr. Chang. 777 00:39:25,457 --> 00:39:26,807 This was a fantastic article. 778 00:39:26,897 --> 00:39:29,477 It is packed with other stuff we didn't touch on. 779 00:39:29,747 --> 00:39:32,187 Just as a teaser, if you're a subscriber. 780 00:39:32,427 --> 00:39:34,857 There's a whole section on pregnant patients. 781 00:39:34,977 --> 00:39:39,117 There's a whole section on neonatal hypothyroidism and thyrotoxicosis, 782 00:39:39,117 --> 00:39:42,027 how to handle that and recognize that in the neonate and a 783 00:39:42,027 --> 00:39:44,217 section on pediatric patients. 784 00:39:44,367 --> 00:39:46,647 So lots of information in here. 785 00:39:46,647 --> 00:39:49,282 I highly recommend you go read it and claim your CME. 786 00:39:50,282 --> 00:39:53,102 I enjoyed the section on subclinical hypothyroidism. 787 00:39:53,312 --> 00:39:56,282 As an ER doctor, that feels like more and more I'm getting a burden 788 00:39:56,282 --> 00:39:58,832 of primary care put on me to initiate treatment for people. 789 00:39:58,982 --> 00:40:02,582 I thought that that was very instructive for me about when I shouldn't be starting 790 00:40:02,582 --> 00:40:06,062 thyroid hormone for the patients that come in with subclinical hypothyroidism. 791 00:40:06,403 --> 00:40:09,133 One more reason to go and read the full article, ladies and gentlemen. 792 00:40:09,223 --> 00:40:11,083 All right, and that's it for today. 793 00:40:11,203 --> 00:40:13,918 I'm Sam Ashoo, and on the other end of the microphone. 794 00:40:14,418 --> 00:40:17,448 Eckler, hoping you be safe and take your Synthroid. 795 00:40:17,864 --> 00:40:18,734 Amen to that. 796 00:40:19,431 --> 00:40:20,211 Be safe everyone. 797 00:40:20,811 --> 00:40:21,591 and that's a wrap. 798 00:40:21,631 --> 00:40:24,231 Thanks for joining us for this episode of Amplify. 799 00:40:24,271 --> 00:40:28,788 I hope you found it informative, and I want to remind you that ebmedicine. 800 00:40:28,818 --> 00:40:34,008 net is your one stop shop for all of your CME needs, whether that be for emergency 801 00:40:34,008 --> 00:40:35,828 medicine or urgent care medicine. 802 00:40:36,108 --> 00:40:39,638 There are three journals, there's tons of CME, there's lots of 803 00:40:39,668 --> 00:40:43,178 courses, there's so many clinical pathways, all this information 804 00:40:43,208 --> 00:40:45,578 at your fingertips at ebmedicine. 805 00:40:45,938 --> 00:40:46,318 net. 806 00:40:46,668 --> 00:40:49,108 Until next time, everyone, I'm your host, Sam Ashoo. 807 00:40:49,448 --> 00:40:50,008 Be safe.