Rosen & Barkin's 5-Minute Emergency Medicine Consult (384 page)

• Rapid onset of symptoms following surgical excision of the parathyroid glands is the most common symptomatic presentation
  
• Symptoms often confused with hyperventilation or anxiety
  
• In the absence of surgery or severe hypomagnesemia, be sure that hypocalemia is not due to sepsis or rhabdomyolysis
  
• With the exception of life-threatening presentations, avoid rapid IV administration of calcium salts
  

• Al-Azem H, Khan AA. Hypoparathyroidism.
  Best Pract Res Clin Endocrinol Metab.
  2012;26:517–522.
  
• Andreoli T, Carpenter C.
  Cecil Essentials of Medicine
  . 7th ed. Philadelphia, PA: Saunders-Elsevier; 2007.
  
• Goldman L, Bennett JC, eds.
  Cecil’s Textbook of Medicine
  . 44th ed. Philadelphia, PA: Saunders-Elsevier; 2012.
  
• Sanctis VD, Soliman A, Fiscina B. Hypoparathyroidism: From diagnosis to treatment.
  Curr Opin Endocrinol Diabetes Obes.
  2012;19(6):435–442.
  
• Shoback D. Clinical practice. Hypoparathyroidism.
  N Engl J Med.
  2008;359:391–403.
  

See Also (Topic, Algorithm, Electronic Media Element)

Hyperparathyroidism

CODES

• 252.1 Hypoparathyroidism
  
• 275.49 Other disorders of calcium metabolism
  
• 279.11 Digeorge’s syndrome
  

BASICS

• Body temperature <35°C
  
• Risk factors:
  
  • Poor temperature regulation:
    
    • Very young
      
    • Advanced age
      
    • Comorbid condition
      
    • Intoxication
      
• Pathophysiology:
  
  • Loss of heat:
    
    • Radiation: Most rapid, 50% of heat loss
      
    • Conduction
      
    • Convection
      
    • Evaporation
      
    • Respiration
      
  • Heat production:
    
    • Shivering
      
    • Nonshivering thermogenesis
      
    • Increased thyroxine
      
    • Increased epinephrine
      

• Dermal disease:
  
  • Burn
    
  • Exfoliative dermatitis
    
  • Severe psoriasis
    
• Drug induced:
  
  • Ethanol
    
  • Phenothiazines
    
  • Sedative–hypnotics
    
• Environmental:
  
  • Immersion
    
  • Nonimmersion
    
• Iatrogenic:
  
  • Aggressive fluid replacement
    
  • Heat stroke treatment
    
• Metabolic:
  
  • Hypoadrenalism
    
  • Hypopituitarism
    
  • Hypothyroidism
    
• Neurologic:
  
  • Acute spinal cord transection
    
  • Head trauma
    
  • Stroke
    
  • Tumor
    
  • Wernicke disease
    
• Neuromuscular inefficiency:
  
  • Age extreme
    
  • Impaired shivering
    
  • Lack of acclimatization
    
• Sepsis
  

Infants have a large body surface to mass ratio Child abuse.

DIAGNOSIS

• Mild (35–32.2°C/95–90°F):
  
  • Initial excitation phase to combat cold:
    
    • HTN
      
    • Shivering
      
    • Tachycardia
      
    • Early tachycardia followed by bradycardia
      
    • Tachypnea
      
    • Vasoconstriction
      
  • Over time with onset of fatigue:
    
    • Apathy
      
    • Ataxia
      
    • Cold diuresis
      
    • Defect in distal tubular reabsorption of sodium and water
      
    • Impaired judgment
      
• Moderate (32.2–28°C/90–82.4°F):
  
  • Atrial dysrhythmias
    
  • Bradycardia:
    
    • Decreased spontaneous depolarization of pacemaker cells
      
    • Refractory to atropine
      
  • Decreased level of consciousness
    
  • Decreased respiratory rate:
    
    • Progressive respiratory depression with CO
      ₂
      retention
      
  • Dilated pupils
    
  • Diminished gag reflex
    
  • Extinction of shivering
    
  • Hyporeflexia
    
  • Hypotension
    
  • J-wave (Osborn wave) on ECG
    
• Severe (<28°C/<82.4°F):
  
  • Apnea
    
  • Coma
    
  • Decreased or no activity on EEG (electroencephalography)
    
  • Nonreactive pupils
    
  • Oliguria:
    
    • Renal blood flow depressed 50%
      
  • Pulmonary edema
    
  • Ventricular dysrhythmias/asystole:
    
    • Cardiac cycle lengthens, resulting in increased intervals
      

Time of submersion for near drowning in cold water.

• May not be able to palpate pulse
  
• May not be able to obtain BP
  
• Pupils dilate <26°C
  

Accurate core temperature confirms diagnosis.

• Finger stick glucose
  
• ABG:
  
  • Temperature correction not needed
    
• CBC:
  
  • Hematocrit rises owing to decreased plasma volume.
    
  • Leukopenia does not imply absence of infection:
    
    • High-risk groups (e.g., neonate, immunocompromised) should receive empiric antibiotics.
      
• Electrolytes, BUN, creatinine:
  
  • Vary during rewarming; recheck frequently, especially creatine phosphokinase (CPK) and potassium (K
    ⁺
    )
    
• Serum lactate
  
• PT, PTT, and platelets:
  
  • Prolonged clotting times, thrombocytopenia common
    
• Toxicology screen:
  
  • Alcohol/drug ingestion common
    

• CXR:
  
  • Pneumonia common complication
    
• EKG:
  
  • Tachycardia to bradycardia
    
  • Atrial fibrillation with slow response
    
  • Ventricular fibrillation
    
  • Asystole
    
  • Prolonged PR, QRS, QT intervals
    
  • J-wave (Osborn waves)
    
  • ST-elevation mimicking acute coronary syndrome
    

• Environmental
  
• Sepsis
  
• Primary CNS disorder
  
• Metabolic
  
• Drug induced
  

TREATMENT

• Patient is not dead until “Warm and Dead”:
  
  • CPR recommended during transport:
    
• Prolonged palpation/auscultation for cardiac activity: 30–45 sec
  
  • Apparent cardiovascular collapse may be depressed cardiac output, often sufficient to meet metabolic demands.
    

• ABCs:
  
  • Supplemental oxygen
    
  • Oral and nasotracheal intubation are safe.
    
  • Place nasogastric (NG) tube postintubation.
    
  • Cardiac monitor
    
  • Warmed D5.9 NS preferred over lactated Ringer:
    
    • Shivering depletes glycogen.
      
• Remove wet clothing and begin passive external rewarming.
  
• Administer Narcan, D
  ₅₀
  W (or Accu-Chek), and thiamine to a patient with altered mental status.
  
• Stress-dose steroids (Solu-Cortef 100 mg IV) for known adrenal insufficiency or treatment failure.
  
• Obtain accurate core temperatures using rectal thermometer.