BTK Endocrine Surgery Emergencies ===

Today we're gonna talk about endocrine surgery emergencies. While most endocrine surgery is elective, there are a few rare emergencies that you may get consulted on in your practice, which are time sensitive, and therefore, a general surgeon may need to know how to manage these critical cases. We're gonna get into the management and helping us to work through these scenarios today are Dr. Becky Sipple. A world renowned endocrine surgeon at the University of Wisconsin Madison. She's an endowed professor at UW Madison and Chief of Endocrine Surgery. She's the most recent past president of the American Association of Endocrine Surgeons and has co-authored over 250 manuscripts. Amanda Doubleday, and myself, Dr. Simon Holbeck, our fellowship trained endocrine surgeons affiliated with UW Health, who focused endocrine surgery practices. I, Simon Holbeck am a paid consultant for Medtronic who

provides educational content for N vital recurrent laryngeal nerve monitoring and pt, eye autofluorescent devices. Alright, let's get into our first clinical scenario, thyroid storm for the patient who cannot tolerate Metrazole. Grave's disease is the most common cause of hyperthyroidism. Most patients present with symptoms that can be effectively managed initially with antithyroid medications. However, in rare cases, patients can present acutely in thyroid storm. Side effects from antithyroid. Medications such as methimazole are common, and in rare cases, patients can prevent life-threatening side effects such as a OC cytosis or acute liver failure. Our objective is for the listener to learn about how to best manage a patient who cannot tolerate antithyroid medications such as methimazole and those who present with thyroid storm. All right guys, let's start with the case. You have a 43-year-old woman with a new diagnosis of Graves disease. She has

fairly significant symptoms of hyperthyroidism, and her heart rate is elevated at 110 beats per minute. She started on Metrazole as well as a beta blocker. She initially starts to improve. A week after starting Metrazole, she develops a fever and a white blood cell count is checked and it's less than a thousand. Her endocrinologist diagnoses her with a gradular cytosis and admits her to the hospital for further evaluation and consults general surgery for an urgent thyroidectomy. So, Dr. Sippel, how common is a granule cytosis and how do you manage this condition? So thankfully a Gran Cytosis is a pretty rare complication of methimazole. But when it develops, patients can develop a dangerously low white blood cell count, and that really can put them at risk for severe infection. It really leads to an immunocompromised. State which can be really problematic for patients. Thankfully, it occurs in about less than 1% of

patients who are treated with methimazole, and it usually presents in just the first three months of medical treatment. So it's much rarer when somebody's been on methimazole for many years. Thankfully when it happens, once you stop the methimazole, it usually will resolve within about one to three weeks. And it tends to be most common in older patients are those who are requiring much higher doses of methimazole. Okay, so in this case, the metrazole is stopped and the patient is admitted for supportive care. Now that the Metrazole is stopped, how do you manage this patient's hyperthyroidism. I think that this is one of those things that people don't always recognize as sort of, not necessarily a surgical emergency, but an urgent surgical consult. 'Cause the effect of methimazole usually wears off within about a week of stopping it. So once a patient develops a complication related to Antithyroid medication and they need to stop the medication, you really wanna. Have that come conversation with the surgeon at that point because you really have about you know,

seven to 10 days to get the patient prepped and ready for the or. So it's really important that you communicate with your endocrinologist and then if they know they have to stop medications for any reason, they're reaching out to you early. Because if you don't and you wait until the patient gets fluidly, hyperthyroid, it is much harder to manage that patient in the acute setting. I would say once you stop the methimazole, you know, you have a short window where they'll still be fairly well controlled because you'll have the residual effects of the methimazole. But if they start to develop symptoms, you can supplement them with steroids. You wanna treat them with beta blockers to help control their heart rate. And you can still give SSKI or LU solution, which can help to treat the hyperthyroidism leading up to surgery. What do you do with the low white cell count? Is it safe to operate on a patient with an A NC of let's say, 300? Yeah, I think ideally we want the, the a NC or the absolute neutrophil count to be about

greater than a thousand prior to taking into the or. So if your a NC is not recovering within the first 48 hours of stopping the methimazole you may wanna give a medication such as granulary. Colony stimulating factor to help facilitate recovery. This can be used to sort of help boost their white count and make it safer to take 'em to the operating room, and it usually can be dis discontinued once their a NC is greater than a thousand. All right. Since this patient had an undetectable TSH, when they admitted to the hospital in order to. Assess the severity of their hyperthyroidism. It's important to check a free T three, T four level as their better real-time markers of thyroid status. It's important to remember that these patients you know, may have a TSH that's undetectable, but that this is not a good short-term marker of thyroid function. I feel like this is a common misunderstanding you know, between a surgeon and anesthesia. Colleagues, they see the suppressed TSH and they become concerned that the patient isn't medically safe. I had

to go to the or this actually just came up in my practice this past week where I was talking with the endocrinologist about a patient who has a suppressed TSH and we were trying to like, get the guy cleared for surgery. So let's say the a NC isn't coming up in a reasonable amount of time, the patient's starting to develop more over hyperthyroidism or thyroid storm. How do you manage acute thyroid? Toxicosis. I would say, depending on the severity of the presentation, if a patient is really tachycardic or having fevers or is unstable you may need to admit them to an ICU for supportive treatment. I think, you know, when you lost your ability to treat them with antithyroid medications, that the most important thing is to treat them with effective beta blockade because you really wanna minimize the cardiovascular. Impacts of that uncontrolled hyperthyroidism. So oftentimes being in an ICU, you can put them in a a, an IV beta blocker drip. You know, I would say that LU solution or SSKI can still be administered especially since they,

this can help to block the census. Synthesis and the release of thyroid hormone. It's important to recognize that iodine is really only helpful in patients with grave disease and can't be used if their hyperthyroidism is related to a toxic adenoma, a toxic multinodular order. 'cause in those cases it can actually add act as a substrate and worsen the TSIs. Ideally you wanna start the SSKI or the Lugo solution after patient has been blocked with Methimazole. But when you have to stop the methimazole acutely, you have some persistent activity that methimazole that's gonna li last for about a week. So it is safe for you to start the SSKI anytime within that first week of stopping the methimazole prior to surgery. I think steroids are another really helpful adjunct that can be used in the setting of acute tux theosis. Typically, if they're in the inpatient setting, we'll give it in the form of IV hydrocortisone or dexamethasone. And dexamethasone tends to be more poor. Potent and

is probably more effective than the hydrocortisone or prednisone and is a better choice in this more acute scenario. And I think that the hyperthyroidism is really refractory to, to traditional treatment. There are some other things that can be used. Cholestyramine can be useful for lowering thyroid hormone levels as an adjunct. And this is just a resin that binds thyroid hormone in the bowel. A typical dose is about four grams, two to four times a day. And another rare treatment option is to use plasma for plasmapheresis. You know, I think thankfully these options are rarely needed. And really the key is effective beta blockade, and usually with steroids and iodine, you can get a patient safely prepared to take him to the or. Okay, in this clinical scenario, you get the patient's hyperthyroidism under control and their a NC comes up to a safe level and you plan to take them to the OR for a total thyroidectomy. So let's start talking about the approach for thyroid surgery itself. So the fibrotic nature of the gland and the increased vascularity can make these

cases quite challenging. Well, most studies have not shown an increase in permanent complications. The temporary complications, including a nerve paresis and hypocalcemia with you know, relation to hypoparathyroidism are higher after total thyroidectomy. For graves, I think anyone who does a lot of thyroid surgery and kind of understand that, and these are just harder cases, and so you may expect to see this a little more often. Dr. Sipple how do you approach surgery for Graves? And is there anything you can do in these cases differently that you think may improve outcomes? Yeah, so I think that knowing complications are higher in these cases. We do do some things different preoperatively for these patients. We treat them both with the SSKI or the Lugo solution as well as preoperative calcium for about seven to 10 days. And we've done some prospective studies that have shown that both of these interventions can play an important role in lowering the risk of transient complications after surgery. So I think part of it is sort of preemptively thinking about how you're gonna minimize things, uh

uh, and make things easier during surgery. But I think during surgery, I think having done a lot of these cases, I do think that I use the approach a little bit differently because of the fibrotic nature. I think that these patients are at much higher risk for attraction injury to the recurrent laryngeal nerve. And what I found is that if you try to do your thyroid a typical way where you sort of elevate the thyroid and retract it medially to expose the recurrent laryngeal nerve, oftentimes the nerve is stuck in that inflammatory reaction posterior to the nerve, and you are at high risk for getting a stretch injury. And that can lead to a transient focal cord dysfunction. Because of that, what I try to do is do everything I can to minimize retraction of the thyroid gland medially until I've been able to identify the nerve. So I often divide the isus of the thyroid early and try to mobilize some of the anterior surface off the anterior surface of the trachea. Then I often will mobilize the upper pole and actually retract it inferiorly so that I can

find the nerve right at its insertion just behind or just below the insertion, into the cricothyroid muscle. By doing so, I'm able to sort of elevate the thyroid away from the nerve and avoid that kind of lifting it up and putting that nerve under traction. Alright, identify identifying the parathyroid glands during surgery can be more challenging due to this fibrotic nature of the gland and increased vascularity. Recently both the European Society of Endocrine Surgeons in their 2025 consensus statement as well as the updated 2025 American Thyroid Association guidelines suggested consideration of the use of autofluorescence in difficult bilateral cases, which, present a risk of hypoparathyroidism, a research on the use of these devices. For parathyroid, autofluorescence appears to be most consistently showing a decrease in transient hypoparathyroidism with only a few studies suggestive of a decreased

rate of permanent hypoparathyroidism after total thyroidectomy. Dr. Sipple, do you have any experience using parathyroid autofluorescence in these cases and could offer perspective here? Yeah. So I mean, we have we've adopted the use. I've, I've trialed both systems, but we have now started using the PTI system in the or. And I would say for a total thyroidectomy, I do think that the patients with Graves or Hashimoto's are the ones where I probably find that there is the greatest utility. Because oftentimes the gland. Stuck in that inflammatory reaction around the thyroid and almost inside the thyroid capsule. And so especially with the PTI, which is a small handheld probe, you can actually scan the capsule of the thyroid as you're mobilizing the upper pole to help identify the parathyroid. And so I think it can be helpful to find a parathyroid that may be just under the capsule or just tuck trapped in that inflammatory rind to help facilitate identification. And so I do think it can be helpful in these cases. All right, so

now we've completed a total thyroidectomy for Graves. Dr. You talked about giving patients calcium preoperatively. What would you do with regards to post-op prevention of hypocalcemia? Yeah, I think that grace patients are just at high risk for a high bone turnover state and, and hypocalcemia. So regardless of what their postoperative PTH or calcium is, they're gonna be at high risk. So because we treat everybody preoperatively, we continue it regardless of what their postoperative PTH status is. We give everybody routine calcium supplementation for least. Two weeks post-op. And then what our protocol is at at University of Wisconsin is we check a PTH level in the PACU on all of our patients who've had a total thyroidectomy or completion thyroidectomy. And based on that PTH, we determine kind of what they need for supplementation For grace patients, we always give them sub scheduled calcium. And then if their PTH is less than 10, we add Calcitriol which is an activated vitamin D that can facilitate calcium absorption. I would

say that if it is less than 10 or between five to 10, we will give them 0.25 micrograms twice a day. And if their PTH is undetectable, then we will. Increase that dose to 0.5 micrograms twice a day. And when I do that, my preference is to actually give them 0.25 microgram tablets, but have them take two twice a day. And the reason I do that is 'cause usually if they make it a week without significant symptoms, you can start to taper that medication off. And if they're on the 0.25 microgram tablets, it's much easier to easily transition them and lower their dose and get them off of the calcitriol. All right. How do you manage their postoperative thyroid hormone replacement and other medications? I mean, I think the important thing is to recognize is that now that you've taken off the thyroid, they're not hyperthyroid anymore. They're not going to be so you can stop all of their antithyroid medications if they're still on it. You wanna stop, obviously the iodine. And then because the hyperthyroidism often caused the

tachycardia and the need for beta blocker, usually you can taper the beta blocker off. Than the postoperative period. It depends how hyperthyroid they are at the time of surgery. If they're coming in still not very well controlled or fairly hyperthyroid, you're gonna continue their current dose of their beta blocker and maybe start tapering it within a week of surgery. But if they're coming in fairly well controlled and they're clinically euthyroid the day of surgery, you could probably half their beta blocker the day of surgery and gradually taper it off. I think the other thing is, is that important to recognize that you wanna start thyroid hormone replacement? And I always give a patient a prescription the day of surgery, but I do warn them that they don't need to start it right away. Especially if they're coming in hyperthyroid or even if they're well controlled, just the manipulation of the thyroid gland can release a lot of thyroid hormone into their system, and so the patient can be functionally hyperthyroid for the first few days after surgery. So I tell the patients to wait until they feel normal. If they wake up and they don't have any

signs of hyperthyroidism, they're feeling normal. Then they should start the thyroid hormone. And that will hopefully keep them feeling normal. But if they're feeling hyperthyroid and they start their thyroid hormone supplementation right away, it's just gonna exacerbate their symptoms and make them feel hyperthyroid. So it is actually totally safe for somebody to wait even up to a week after surgery to start the thyroid hormone and supplementation postoperatively. All right. This takes us into our second clinical scenario. Thanks Simon and Dr. S. It was great. So my name's Amanda Doubleday. As Simon said, I'm an endocrine trained surgeon as well. So we're gonna talk about Hypercalcemic crisis in the setting of primary hyperparathyroidism. So hyperparathyroidism in general is probably an underdiagnosed condition. We can see decreased bone density and as a result increased risk for fractures and kidney stones or progressive renal disease and among other psychosomatic symptoms. And this can

decrease the patient's quality of life. So we, we chose to review treatment of hypercalcemic crisis due to uncontrolled primary hyper parathyroidism. So first clinical scenario here. Let's say we've got a woman in the emergency room. We've been con consulted by the ER for a 75-year-old female who was found down with altered mental status. Her calcium is about 15.5. She's hyponatremic with a sodium of 1 22 and in acute kidney injury with creatinine up from her. What baseline is normal up to 3.1. So this would be considered severe hypercalcemia, and as we're seeing this is she's presenting with associated altered mental status and dehydration. So we'll assume at this point the pa, the patient has already been started on IV food resuscitation in the emergency room with normal saline. We're treating her hypovolemia and her hypo natremia. And so let's say the, the ER and or endocrinology suggests

to start with. Calcitonin and or bisphosphonates. So these are adjunctive therapies that can help. But Dr. Sippel, what are some of the caveats about these therapies and what would you caution about? Yeah, so I think it's important to recognize that really probably the, the most effective treatment is just effective hydration. That really just with, especially in this patient, is coming in acutely dehydrated. That is usually the precipitating factor of a hypercalcemia crisis. So IV fluid resuscitation may actually normalize a calcium to a reasonable range in many patients. If that's not working. One of the challenges is with bisphosphonates, which is typically what most physicians will give, is that they don't have a peak impact for at least three to five days. And so while it will help to lower the calcium, the onset of action isn't gonna be for three to five days. And if you're evaluating this patient. You know, in the inpatient setting, most of the time you're going to get consulted and potentially

take the patient to the operating room for a parathyroidectomy long before that, that five day window. And so it really can create problems for you in the postoperative setting because the peak onset of action might not be until post-op day one or two. And so this patient, once you treat their hyperthyroidism or hyperthyroidism, is gonna develop fairly significant postoperative hypocalcemia. And that's just gonna be exacerbated. If the peak onset of action of the bisphosphonates is in the immediate postoperative period calcitonin is always listed as a treatment option and UpToDate, and I think that a lot of physicians will contemplate it, but I actually have seen it pretty rarely used. It does have a peak onset within just the first few days, so especially if you're gonna plan to take the patient to the OR in the first couple days, it can be a useful adjunct to sort of acutely lower the, the. Calcium in preparation to take him to the or. Okay, great. So at this point now we've addressed the

hypercalcemia and our next step is to confirm the cause that this is actually due to hyperparathyroidism. So if we're suspicious of primary hyper para and. The ER has called general surgeon or endocrine surgeon. We'll need to confirm elevated PTH. In my outpatient practice, I generally will check a vitamin D as well in the workup. But in this er acute setting, it's probably not as necessary initially. So hypercalcemia with, let's say an undetectable PTH, which would be a normal physiologic response to hypercalcemia, would pretty much rule out primary hyper parathyroidism. So I'd advise the workup in that case for other causes of the hypercalcemia, such as malignancy, multiple myeloma, et cetera. So I think in those cases, I would probably recommend an endocrinology or a hemon consult. So, okay, so let's say we check PTH, it's 250 presentation with hypercalcemic crisis, then would weight

would raise concern potentially for a rare condition of parathyroid cancer. However, most of these are benign. I don't think this would change my initial imaging workup, but would probably change my operative approach if I was concerned about cancer. I would probably start with an ultrasound as maybe a newer or a younger or less experienced faculty member. Or if, let's say a general surgeon who doesn't really do parathyroid surgery often in their practice. It may be also very helpful or useful to get a 40 CT neck. So Dr. Silva, what would be your approach and what findings would make you concerned about parathyroid cancer? Yeah, I think that the classic teaching is always the significant hypercalcemia with that palpable neck mass is parathyroid cancer. And so I do think we have to raise our suspicion of parathyroid cancer in this acute setting, but I would say that the vast majority of 'em still end up being benign even in this scenario. You know, I thought, you know, my thought was always that these are always gonna be just an obvious

big adenoma, but my, my personal experience has been, is that most of the time when I get consulted, I have frequently found a double adenoma. So I think that multi gland disease is not actually that rare in this scenario. So I agree with you. I think ultrasound is always my first imaging of choice, and I think in this scenario you know, it can actually help you to raise the suspicion of parathyroid cancer. While a typical parathyroid on ultrasound is a hypo coic has well. Described margins and has a vascular pedicle going to it. Parathyroid cancer has a very heterogeneous appearance. It may have irregular borders, it may be fused with a thyroid gland. Honestly, the few parathyroid cancers that I've seen on ultrasound honestly look more. Almost like, a small thyroid cancer. And so, if you're doing imaging and it looks actually suspicious for thyroid cancer in a patient with a hypercalcemic crisis, I would be very concerned that this is potentially parathyroid carcinoma. I do think that a four D CT scan is not a bad idea.

Frequently because of that risk of a double adenoma, because you may see one obvious adenoma and ultrasound, but knowing that they're at higher risk for potentially having a second gland, that CT scan may help you to know where that gland is. Because I think especially with the PTH levels being as high as they often are in these patients, and intraoperative PTH tests may not be as reliable to rule out multi gland disease. And so I do think a four D CT scan can can be a helpful adjunct for. I would say that, you know, if you are concerned about parathyroid cancer intraoperatively, I think honestly, frozen section just doesn't play a role in making this diagnosis. This has to be your own clinical suspicion. So if you get in there and the parathyroid is. Firm and fibrotic and adherent to the thyroid gland. That is not a typical benign adenoma. You have to raise your concern for parathyroid cancer. So I would say that if you get in intraoperatively, the palpation and the findings just do not look like a

typical benign adenoma, then you probably should assume it could be a parathyroid cancer and treated as such. And really the main principles is that you do not wanna disrupt the capsule of the parathyroid. Because even if it's not a cancer, and it's just like an atypical adenoma, if you disrupt the capsule and spill cells, those cells can implant and all the tissues in the neck, and you can get a condition called parathyroid dermatosis which is really just a local recurrence problem. And so you really wanna try to avoid doing that. You also wanna make sure that you're not just taking out the parathyroid gland, but any tissue that it's attached to or adherent to. So if it's directly adherent to the thyroid gland, you wanna do an unblock resection with that thyroid lobe. And you don't necessarily need to do a central neck dissect 'cause these don't tend to spread to lymph nodes. But you wanna remove the surrounding fibro fatty tissue around the gland because you worry about local recurrence. So I would say that if you're trying to do an unblock resection, I think for a lower

gland it's pretty straightforward. The gland is just adherent to the lower pole. You just do a simple thyroid lobectomy. You can take out the parathyroid unblock. It does get a lot more tricky when it's an upper gland. Because if we think about our anatomy and our teaching, the recurrent laryngeal nerve runs between the right upper parathyroid gland and the right and the thyroid. So if you're trying to find the nerve, it can be really tricky if you're trying to keep the two structures attached. So I think for an upper gland if you're worried about parathyroid cancer, again, you probably have to do just. Slightly different approach. I would say. I typically will divide the isus. I will mobilize as much as I can of the lower pole and try to find the nerve low in the neck and trace it up superiorly and I may actually mobilize the upper pole and try to find the nerve superiorly and then try to connect it. And frequently in order to leave the two structures adjacent to each other, you may actually have to mobilize it entirely off the trachea and push the

dissection of both the thyroid lobe and the parathyroid laterally. In order to remove it on block. I think it's just important to recognize that these are cases that a nerve monitor is gonna be incredibly helpful. So if you don't routinely use it for parathyroid surgery, I think it's probably a very safe thing to always use a nerve monitor when you're operating on hypercalcemic crisis, just in case. Great. Yeah, that's, that's a really good review of such a rare thing and so good tips. So. If we have a recurrent laryngeal nerve that is sort of stuck to this fibrotic, what we're concerned about is cancer, or let's say it's even invading. We know risk of recurrence for parathyroid cancer is really high up to in some. Studies or textbooks, they'll quote up to 50%. So I think I would probably be much more aggressive to resect the nerve if I couldn't free it up. Instead of, let's say like shaving it off with a blade. So if we have to do that,

we know we'd like to create a tension free anastomosis. And after, so, after we. Create clear margins of getting all that tumor off the nerve. Let's say we can create attention free anastomosis primarily. And, and so I know that there are some reports, and I have seen this a few times where we can swing the Ansys cervical down and do a primary anastomosis that way. Dr. Sipple, would you agree with that? I know this is not done super commonly, but if you had to create this recurrent laryngeal nerve to the anastomosis, how would you do it? Yeah. So I think that you know, I think when we're thinking about recurrent laryngeal nerve involvement in neck operations, I think we think about it a little bit differently in parathyroid cancer versus thyroid cancer and thyroid cancer. I think as long as the nerve is still functioning, we tend to try to preserve the nerve insight too. We'll try to shave the tumor off knowing that even if we leave a positive margin, we have the adjunct called radioactive iodine that can potentially help destroy any residual tissue there. And that we

don't wanna necessarily resect the nerve if it's still functioning. However, in parathyroid cancer, you don't have that adjuvant therapy to give, and so leaving a positive margin is gonna risk local invasion. And especially if it's at the nerves insertion, you're gonna worry about recurrence and invasion of the trachea or the esophagus. So I think I would probably resect the nerve and, and like you said, always try to do a primary anastomosis whenever possible. Usually if you mobilize the nerve into the upper mediastinum, you can get quite a bit of laxity to usually be able to do a primary repair. Even if you have to resect a centimeter or more of the nerve. But if for some reason you have to resect more than that, and it's just not feasible to do a primary repair, what you just wanna do is identify the ansa, and usually you can do that. It's in the, you know, the anterior carotid sheath. Usually just above the IJ is where you'll find the answer. You just wanna dissect it as distal as you can so you have the

most laxity to sort of mobilize it and swing it over. And then you would again, just do a primary repair. I would say that oftentimes you'll mobilize it off the anterior ij and then tuck the nerve underneath the strap muscles is to bring it into the central next, so you can do a primary repair. Really with this, you're not bringing back function of the nerve. You're just re approximating the nerve end so that it can maintain kind of, nerve function and it basically allows the nerve, or, or the muscle to maintain tone in bulk so it doesn't atrophy. So while they won't have a functioning nerve and it, that muscle will never move again. If it maintains that bulk and tone, you can get actually a very good voice outcome by about six months after surgery. Okay, great. So. So let's say, you know, going back to benign disease let's say we have imaging, it identifies several lesions, probably have less

of a threshold to do a for gland exploration. So we've done our surgery now now let's say postoperatively we wanna prevent hypocalcemic symptoms, which we assume are going to happen. I start all my patients on BID calcium. Which in the form of Tums and then add additional calcium, PRN Dr. S Sipple, is there anything else that you would say about how to counsel these patients postoperatively if they do develop hypocalcemia symptoms? Yeah, so I would say hypocalcemia is gonna be a significant issue for this patient just 'cause they present with probably significant bone hunger. Patients are always confused 'cause they're like, well, why do I have hypocalcemia? I thought I had too much calcium. But really it's just taking the calcium out of their bones and putting their bloodstream in. Screening it. And so their total body stores of calcium are very depleted. So a lot of times patients will need aggressive supplementation after surgery. Think as long as they're responding to calcium supplementation, then just giving them more calcium. One of the caveats

is calcium carbonate, which is tums can be constipating. So if they're requiring a large amount of calcium supplementation, you may wanna consider switching to calcium citrate. Which is a little bit more gentle on the stomach and doesn't have the constipation side effects. If they're having trouble absorbing the calcium, you always wanna figure out why. If they're vitamin D deficient, you wanna supplement their vitamin D. And, and if it's really low, you may actually need to give them activated Vitamin D or Calcitriol just to help them facilitate calcium absorption. Another thing you wanna do is check if they're on a PPI. So if they're on acid suppressant medications. Calcium carbonate in particular requires an acidic environment for absorption. So we wanna make sure that we are, are stopping their PPI if necessary to facilitate calcium absorption. Alright, let's talk quick. Hit. All right. Number one. If you need to stop methimazole for a Graves patient who does not tolerate these

medications, we advocate getting 'em to the operating room within about seven to 10 days to avoid them from becoming forwardly, hyperthyroid. Second, total thyroidectomy for graves can be challenging, and therefore preop preparation with methimazole, beta blocker and luol is best. When possible, consider modifying your operative approach and using adjunctive technology like nerve monitoring and parathyroid autofluorescence when available. And last. Hypercalcemia in the emergency department should be treated initially with IV normal saline. While some medications may help decrease the calcium level, they typically do not peak for more than 24 hours, and therefore less useful if you plan to get the patient to the operating room for parathyroidectomy soon. But they can be a little more helpful when these patients have to wait for several days, dominate the day.