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INTRODUCTION

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While endocrine and immunologic emergencies may not hold the dramatic appeal of a multiple trauma they are no less fatal and often are definitively treated by medical intervention alone. The EMS physician stands to have a significant impact on the outcome of those diagnoses and management schema that fall outside the traditional ALS curriculum and yet are rapidly treated by appropriate medical intervention. In this chapter, we will review likely endocrine and immunologic emergencies that may be encountered in the field where there is opportunity for the EMS physician to provide diagnosis and intervention with those tools available in the prehospital environment.

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OBJECTIVES

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  • Describe the initial prehospital evaluation and management of hyperglycemia, hyperglycemic hyperosmolar syndrome, and diabetic ketoacidosis.

  • Describe the initial prehospital evaluation and management of hypoglycemia.

  • Describe the initial prehospital evaluation and management of thyroid storm.

  • Describe the initial prehospital evaluation and management of adrenal insufficiency.

  • List causes of immune deficiency.

  • List common autoimmune diseases in prehospital patients.

  • Describe the initial prehospital evaluation and management of allergic reactions

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THYROID EMERGENCIES

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MYXEDEMA COMA

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The initial approach to the patient with altered sensorium is covered in Chapter 36. Upon completion of the initial priorities and screening for the more common sources of altered sensorium the possibility of myxedema should always be considered. The clinical stigmata of generalized slowing across all organ systems are readily assessed without the need for advanced testing modalities. A careful history from family or friends as well as review of the patient's prescriptions, if available, may yield valuable clues to the diagnosis. Obviously specific history of thyroid disorder is pivotal and one should bear in mind that history of hypo- or hyperthyroidism suggests the diagnosis in the appropriate clinical context. A patient who is undergoing radioablative or pharmacologic therapy for hyperthyroidism is as much at risk as the patient who neglects to take their thyroid supplementation in the presence of diagnosed hypothyroidism. Further historical screening should focus on complaints of fatigue, cold intolerance, and especially somnolence.1,2 The presence of an acute superimposed illness over baseline hypothyroidism can precipitate an acute crisis particularly when the diagnosis of hypothyroidism was previously undiscovered or underreplaced.1,2 In addition to altered sensorium the expected physical examination findings include bradycardia and hypothermia along with hyporeflexia.1,2 The classical skin and hair changes of the disease are further supportive as is any evidence of surgical thyroidectomy. A depressed EtCO2 in the setting of normal minute ventilation may be a clue to the hypometabolic state.3

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The management of myxedema focuses on the acute replacement of the deficient steroids. If practical, blood can be drawn and saved for later analysis of the TSH, free T4, and cortisol levels preceding treatment. The dose of T4 varies in the literature with no large-scale RCTs to convincingly support one ...

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