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TRANSCRIPT
9/18/15
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The Pressures of Non-‐Compliance
Craig Destree, MD
Rachel Hawker, MD, FACP
2015 State ACP Conference September 11, 2015
Emergency Department
• A 49 female presented with lower extremity weakness. – Progressive worsening over 4 weeks – Unsteady balance – Recurrent falls – Swelling in hands, calves and feet
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Medical History
• Hypertension – Metoprolol tartrate, 150mg daily – Hydrochlorothiazide, 25mg daily
• SedaRves – Hydroxyzine, 50mg TID prn – Mirtazapine, 30mg at bedRme – Hydrocodone-‐acetaminophen, 5-‐325mg q6h prn – Methocarbamol, 750mg TID
• Hypothyroidism – Levothyroxine 175mcg daily; endorsed compliance – Last TSH 1.5 years ago was normal
Vitals and Physical Exam
• T 36.4 HR 71 BP 135/99 RR 14 SaO2 98% • Heart: irregularly irregular rhythm • Respiratory: notably hoarse voice • HEENT: puffy face • Skin: – Dry, coarse – Diffuse alopecia
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Lower ExtremiRes
• Non-‐pi`ng edema • Absent DP and PT pulses • Lea leg tenderness • Right leg – Foot drop – Diminished sensaRon
IniRal InvesRgaRons
• Blood Work (Abnormal only) – CPK > 20,000 (upper limit of assay) – AST 510 – Na 110
• Urinalysis – 3+ Occult Blood – 0 RBCs
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Compartment Pressures
• Acute compartment syndrome definiRon: – Compartment pressure > 20mmHg – Delta Pressure < 30mmHg
• Right leg calf compartment pressure: – Compartment pressure 103 mmHg – Delta pressure 0 mmHg
• Lea leg calf compartment pressure: – Compartment pressure 60 mmHg – Delta pressure 43 mmHg
CT Tibia and Fibula
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Fasciotomies
Severely Hypothyroid
TSH >100 Free T4 < 0.10
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Severely Hypothyroid
TSH >100 T4 < 0.10
Non-‐compliant with levothyroxine
AtraumaRc Compartment Syndrome
• Reperfusion Injury • Bleeding Disorders • Vascular Disease • Animal Venom • ExtravasaRon of IV Fluids • OsteomyeliRs • Burns • Prolonged lying • Viral MyosiRs
• IV Drug Use • Exercise • StaRn-‐induced • Intramuscular hemorrhage (anR-‐coagulaRon)
• Methanol • Sapheneous vein harvesRng • Phlegmasia cerulea dolens • Hypothyroidism
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100
105
110
115
120
125
130
135
140
0 2 4 6 8 10 12 14 16 18 20
Serum Na
0
0.2
0.4
0.6
0.8
1
1.2
0 2 4 6 8 10 12 14 16 18 20
Free T4 (Ref 0.90 -‐ 1.70)
Treatment
• Liothyronine (T3) -‐5mcg BID
• Levothyroxine (T4) -‐100mcg IV Daily
• ±HydrocorRsone
R² = 0.94
R² = 0.96
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Mechanism
• Anatomical predisposiRon • Muscle Pseudo-‐hypertrophy – Remodeling • Loss of atrophic fast-‐twitch fibers • Gain of hypertrophic slow-‐twitch fibers
– Glycogen deposiRon
Mechanism
• Glycosaminoglycan deposiRon – Extracellular matrix expansion – Fluid retenRon
• Increased capillary permeability – Capillary leak of plasma fluid – ExtravasaRon of plasma protein
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Summary
• Hypothyroidism can cause compartment syndrome.
Summary
• Hypothyroidism can cause compartment syndrome.
• Trust but verify (your paRent history)
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Summary
• Hypothyroidism can cause compartment syndrome.
• Trust but verify • QuesRons?