Hypothyroidism and Hyperthyroidism
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Hypothyroidism and Hyperthyroidism Presentation Transcript

  • 1. Hypothyroidism and Hyperthyroidism in the Elderly Chien Yung-Chang , MD .
  • 2.  
  • 3. Free T4
    • Reference range 0.7-1.8 ng/Dl .
    • Converted to triiodothyronine (T3) .
    • The thyroid gland is the sole source of T4 .
    • Free T4 measures the nonprotein-bound circulating T4 .
  • 4. Total T4
    • Normal range 50-120 ng/mL , 5-12 mcg/dL .
    • Measurement of total T4 is not particularly helpful .
    • Only 0.03% of T4 circulates in the unbound state .
    • There is no clinical indication for performing total thyroid hormone measurement .
  • 5. TSH
    • Normal 0.4-5.5 mIU/L .
    • Serum TSH will be decreased to<0.1 mIU/L in most hyperthyroid patients .
    • The findings of a low serum T4 and low TSH mandate a search for pituitary disease .
  • 6. T3
    • T3 is more biologically active .
    • Binding proteins : thyroid-binding globulin , transthyretin and albumin .
    • T3 thyrotoxicoisis : approximately 5% of clinically hyperthyroid patients with a normal free T4 level .
  • 7. Functional examinations
    • Measure the uptake of iodine into the thyroid gland .
    • The iodine isotopes : used to identify nodular thyroid disease , to determine if these nodules are hot ( functioning ) or cold ( hypofunctioning ) , to determine the cause for the hyperthyroid state ( Graves’ disease vs thyroiditis ) and to determine a dose of radioiodine for treatment .
  • 8. Erythrocyte sedimentation rate
    • To confirm the diagnosis of subacute ( viral ) thyroiditis in patients with tenderness on thyroid palpation .
  • 9. The Role of the History in Diagnosing Hypothyroidism
    • Previous thyroid ablation .
    • Elevated thyroid autoantibodies .
    • Thyroid surgery .
    • Medicatins containing lithium or iodine .
    • The most common cause of hypothyroidism is autoimmune or Hashimoto’s thyroiditis .
  • 10. Signs and Symptoms of Hypothyroidism
    • Less active than usual with loss of interest in things previously enjoyed .
    • Lethargy , and decreased mobility .
    • Fatigue .
    • Dry skin .
  • 11. Sings and Symptoms of Hypothyroidism (continued )
    • Apathy and psychomotor retardation .
    • Weakness , arthralgia , myalgia , coarsening of the voice , constipation , edema , weight gain , cold intolerance .
    • Alveolar hypoventilation => CO2 retention and coma .
  • 12. The Physical Examination in Hypothyroidism
    • Hypotension or diastolic hypertension .
    • Low body temperature and bradycardia .
    • Facial features that are puffy and coarse .
    • The skin : dry and cold .
    • Carotenemia : An orange or yellow tint without scleral icterus .
  • 13. The Physical Examination in Hypothyroidism ( continued )
    • Brittle nails and hair , pallor , induration and thickening of skin , periorbital edema , macroglossia , and myxedema .
    • Mental status change .
    • Delayed relaxation time of deep tendon reflex .
    • Pleural , peritoneal and pericardial effusion .
    • Delirium and psychosis .
  • 14. The Heart in the Hypothyroid State
    • Decreased stroke volume , bradycardia , and decreased cardiac output .
    • Diastolic hypertension .
    • Sinus bradycardia and a prolonged PR and QT intervals .
    • Low voltage , heart block , T-wave flattening or inversion , Torsades de pointes , and sudden death .
  • 15. The Heart in the Hypothyroid State ( continued )
    • Echocardiogram may be useful to show regional wall abnormalities .
    • It also will diagnose a pericardial effusion .
    • Pericardial tamponade is rare .
  • 16. Laboratory Diagnosis of Hypothyroidism
    • Levels of TSH : high .
    • The levels of free T4 : decreased .
    • Vitamin B 12 deficiency => macrocytic anemia .
    • Erythropoietin levels also are low => fall in hematocrit .
    • Hyponatremia with low serum osmolality .
  • 17. Laboratory Diagnosis of Hypothyroidism ( continued )
    • Hypoglycemia .
    • Cardiac enzymes may be elevated .
    • Without AMI , the troponin I level remains normal .
    • Adrenal hypofunction .
  • 18. Laboratory Diagnosis of Hypothyroidism ( continued )
    • Elevation of thyroid microsomal antibodies is => chronic autoimmune ( Hashimoto’s ) thyroiditis .
    • Thyroid antibodies may be associated with : Grave’s disease , vitiligo , myasthenia gravis , Addison’s disease , pernicious anemia , and other autoimmune diseases .
  • 19. The Diagnosis of Myxedema Coma
    • Abnormal TSH and free T4 values : confirm the diagnosis .( in the presence of nonpitting edema , hypoventilation , hypothermia and stupor )
    • Hyponatremia , hypoglycemia , and associated infection : confirmatory .
  • 20. Precipitating Events for Myxedema Coma
    • Surgery , severe infection , and trauma .
    • Sedatives , narcotics , and tranquilizers .
    • Missed doses of T4 .
  • 21. Clinical Features of Myxedema Coma
    • Alteration in mental status , presence of a precipitating factor , hypothermia , and increased serum CK levels .
    • Pale and edematous .
    • Respiratory symptoms .
    • Ascites , pericardial effusion and pleural effusion .
  • 22. Clinical Features of Myxedema Coma ( continued )
    • Distant heart sounds , bradycardia , high serum cholesterol levels and low voltage on the EKG .
    • Dyspnea on exertion , fatigue , and edema .
    • Distended abdomen , paralytic ileus , and fecal impaction .
    • Myxedema megacolon : pseudomembranous colitis and intestinal ischemia .
  • 23. Clinical Features of Myxedema Coma ( continued )
    • Disturbance in consciousness : ranging from delirium to stupor and coma .
    • Hallucination ( myxedema madness ) , cerebellar signs and somnolence .
    • Muscle relaxation times of the deep tendon reflexes : delayed markedly .
    • Hyponatremia => seizure and depressed level of consciousness .
  • 24. Laboratory Database of Myxedema Coma
    • Serum TSH and free T4 levels , blood glucose , electrolytes , and arterial blood gas .
    • Serum cortisol .
    • Chest films , urinalysis , and blood cultures .
    • CK , and SGOT .
    • Serum electrolytes ,creatinine , BUN ,and glucose should be monitored .
  • 25. Treatment of Myxedema Coma
    • Thyroid hormone replacement : the definitive treatment .
    • Intravenous therapy : preferred .
    • Give steroids when starting thyroid replacement => avoid precipitating adrenal crisis .
    • Passive rewarming and maintenance of appropriate hydration status .
  • 26. Factors Associated with poor come
    • Advantaged age .
    • Body temperature lower than 93*F .
    • Hypothermia persisting more than three days .
    • Bradycardia less than 44 beats/minute .
    • Hypotension , MI ,and sepsis .
  • 27. Initiation of Treatment in ED for Myxedema Coma
    • 200-300 mcg ( 4 mcg/kg ) IV bolus thyroxine , followed by 50-100 mcg QD .
    • T3 20 mcg IV bolus ( loading dose 10-25 mcg ) , then 10 mcg Q8-12H for 24-48 hours until the patient is conscious and taking maintenance T4 .
    • Hydrocortisone 100 mg Q8H .
  • 28. Initiation of Treatment in ED for Myxedema Coma ( continued )
    • Evidence of infection =>Antibiotics .
    • Underlying illness => Supportive care .
    • Consider elective intubation .
    • Severe hyponatremia => Consider hypertonic saline .
    • Consider appropriate rewarming technique .
  • 29. Recommendation for Admission for the Hypothyroid Patient
    • Clinical diagnosis of myxedema coma => ICU admission .
    • Body temperature less than 93*F or bradycardia less than 44 beats /min => ICU admission .
    • Comorbidity : CHF ,cachexia , COPD , pneumonia , or any pulmonary problem .
  • 30. Recommendation for Admission for the Hypothyroid Patient ( continued )
    • Underlying disorder : aspiration pneumonia , urosepsis , MI .
    • CNS dysfunction : Seizure , ataxia , somnolence , lethargy , confusion , or coma .
    • Behavioral disorders : Disorientation , paranoia , or hallucination ( myxedema madness ) .
  • 31. Recommendation for Admission for the Hypothyroid Patient ( continued )
    • Hypoglycemia : suggesting hypopituitarism or adrenal insufficiency .
    • Hyponatremia less than 128 mEq/L .
    • Social factors that jeopardize patient safety .
  • 32. Symptoms and Signs of Thyrotoxicosis
    • weight loss ( the most common ) , palpitation , weakness , dizziness and syncope .
    • Alteration in mental status .
    • Heat intolerance .
    • Nervous or restlessness .
  • 33. Symptoms and Signs of Thyrotoxicosis ( continued )
    • Tracheal compression => SOB, hoarseness , wheezing and stridor .( Pemberton’s sign )
    • Thyromegaly => wheezing , hoarseness , stridor , or dysphagia .
    • Myopathy : the proximal muscle groups of the shoulder and pelvic girdles .
  • 34. Symptoms and Signs of Thyrotoxicosis ( continued )
    • Memory loss , confusion and short attention span .
    • Chorea , delirium , convulsion , stroke , cerebral venous thrombosis , and coma .
    • Some psychiatric conditions => may be mistaken for thyrotoxicosis .
  • 35. Physical Findings in the Hyperthyroid State
    • Flushed skin.Hyperhidrosis of the palms and soles . Alopecia . Fine and brittle hair .
    • Fever and tachycardia .
    • Lid lag , chemosis , exophthalmosis , vasodilation of the conjunctiva , edema of the lids , and compromised visual acuity .
    • Myxedema of the pretibial areas , feet , and toes .
  • 36. Physical Findings in the Hyperthyroid State ( continued )
    • Diffuse enlargement , bruit , nodules , and tenderness.
    • Abdominal pain or secretary diarrhea .
    • Muscle weakness , hyperactive reflexes , and tremor .Alteration in mental status .
    • Dementia and severe psychomotor retardation . ( Apathetic hyperthyroidism )
  • 37. The Heart in Thyrotoxicosis
    • Diminished diastolic BP . Palpitation .Decreased exercise tolerance . Dyspnea on exertion .Elevated systolic BP . Sinus tachycardia . Atrial fibrillation . Anigina pectoris .
    • EKG : shortening of the PR interval , ST change , or atrial fibrillation .
  • 38. Laboratory Testing in Thyrotoxicosis
    • Suppressed TSH levels and increased serum free T4 estimates : clinically evident thyrotoxicosis ( 95% ) .
    • Radioactive iodine uptake => incereased .
    • ESR => elevated markedly .
    • Serum thyroglobulin => increased .
  • 39. Thyroid Storm
    • A life-threatening crisis .
    • Estimated mortality : 20-30% .
    • the result of thyroid surgery .
    • Caused more often by antecedent Grave’s disease .
  • 40. Precipitants of Thyroid Storm
    • Surgery .
    • Radioiodine therapy .
    • Iodinated contrast dyes .
    • Thyroid hormone ingestion .
    • Diabetic Ketoacidosis .
    • Cerebrovascular accident .
    • Pulmonary embolism and CHF .
  • 41. Pathophysiology of Thyroid Storm
    • 1) An acute decrease in thyroxine-binding globulin => high levels of free hormone .
    • 2) Thyroid hormone increases the density of beta-adrenergic receptors & alters responsiveness to catecholamines at a postreceptor level .
  • 42. Diagnosis of Thyroid Storm
    • Largely a clinical diagnosis .
    • CNS disturbances occur in 90% of patients .
    • Atrial arrhythmia and ventricular tachyarrhythmia may complicate high output CHF .
    • Many of the stigmata of the hyperthyroid state may be present .
  • 43. Laboratory Diagnosis of Thyroid Storm
    • A combination of low TSH and elevated free T4 => makes the diagnosis .
    • If TSH is lower than normal and free T4 is normal => free T3 testing is recommended .
    • ED measurement of thyroglobulin or thyroid antibodies : No indication .
  • 44. Treatment of Thyroid Storm
    • Block hormone synthesis with either :
    • a) Propylthiouracil 100-600 mg loading PO or NG , 200-250 mg q4h for total daily dose of 1200-1500 mg ; or
    • b) methimazole 20 mg PO ( 10-40 mg range ) q 4h .
  • 45. Treatment of Thyroid Storm ( continued )
    • Inhibit hormone release :
    • Iodides –Potassium iodide ( SSKI ) 5 drops PO Q6-8H , or
    • Lugol’s solution 7-8 drops ( 1 mL PO Q6H ) or
    • Ipodate 1-3 g daily ( as 1 g Q8H for 24 hours , then 500 mg Q12H ) .
    • If severe iodide allergy , lithium carbonate 300 mg Q6H .
  • 46. Treatment of Thyroid Storm ( continued )
    • Glucocorticoids : Hydrocortisone ( 300 mg IV , then 100 mg IV q8h ) ; dexamethasone ( 2 mg Q6H ) .
    • Adrenergic blockade : Propranolol ( 0.5-3 mg IV over 15 minutes slow IV , then 60-80 mg PO Q4H ) ; Esmolol ( 0.25-0.5 mcg/kg loading , infusion of 0.05-0.1 mcg/kg/min ) .
  • 47. Adjunctive Therapy for Thyroid Storm
    • Treat fever aggressively with acetaminophen .
    • IV fluid containing 10% dextrose are recommended .
    • Administer vitamin supplements , including thiamine .
    • Treat CHF with conventional methods .
  • 48. Adjunctive Therapy for Thyroid Storm ( continued )
    • Identify the precipitating event , including infection .
    • Consider plasmapheresis , hemodialysis or peritoneal dialysis for removal of metabolically active hormone .
  • 49. Admission Criteria for the Hyperthyroid Elderly Patient
    • Impending or clinical thyroid storm .
    • Clinical hyperthyroidism and :
    • a) CNS effects , including agitation , chorea , delirium , psychosis , seizure , or coma ;
    • b) GI effects such as frank diarrhea , vomiting , jaundice , dehydration , or abdominal pain ;
  • 50. Admission Criteria for the Hyperthyroid Elderly Patient ( continued )
    • c) Cardiovascular dysfunction , including CHF , sinus tachycardia unresponsive to oral beta blocade in the ED , new onset atrial fibrillation , or angina pectoris ;
    • d) Persistent fever > 100.4*F after rest , without source or without easily treatable source ;
    • e) Syncopal episode ;
  • 51. Admission Criteria for the Hyperthyroid Elderly Patient ( continued )
    • f) History of recent radioiodinevtherapy ; or
    • g) Thyrotoxic periodic paralysis ( address hypokalemia ) .
    • Underlying precipitating cause .