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Thyroid Storm

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Thyroid Storm signs and symptoms, management...

Thyroid Storm signs and symptoms, management...

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Thyroid Storm Thyroid Storm Presentation Transcript

  • THYROTOXIC CRISIS
  • INTRODUCTION
    • clinical manifestation of an extreme hyperthyroid state
      • morbidity
      • disability
      • death
  • thyroid storm
    • Before
      • common complication of toxic goiter surgery
      • intraoperative and postoperative
    • Today
      • more commonly seen in a thyrotoxic patient with intercurrent illness or surgical emergency
      • Untreated or inadequately treated patients
    • Early recognition and prompt intervention are necessary to prevail in management of this phenomenon
  • Etiology
    • Exact cause unknown
    • A precipitating factor usually is found with thyroid storm
      • Stress (most common)
      • Concurrent illness e.g., sepsis
      • Surgical emergency
    • thyroid storm can occur in
      • Graves disease (more common)
      • toxic adenoma
      • multinodular toxic goiter
    Etiology
  • Mortality/Morbidity
    • fatal when untreated
    • mortality: 20-30%
  • Signs and Symptoms Thyroid Storm Uncomplicated Thyrotoxicosis Confusion, agitation, delirium, frank psychosis, seizures, stupor or coma Anxiety, restlessness Nausea, vomiting, severe diarrhea, abdominal pain, hepatocellular dysfunction-jaundice Diarrhea, increased appetite with loss of weight Heart rate faster than 140 beats/min, hypotension, atrial dysrhythmias, congestive heart failure Sinus tachycardia, heart rate 100-140 Hyperpyrexia, temperature in excess of 106 o C, dehydration Heat intolerance, diaphoresis
    • unusual presentations
      • chest pain
      • acute abdomen
      • status epilepticus
      • stroke
      • acute renal failure due to rhabdomyolysis
      • apathetic thyroidism
    Signs and Symptoms
    • apathetic thyroidism
      • masked hyperthyroidism
      • first described by Lahey 60 years ago
      • present without goiter, ophthalmopathy, or prominent symptoms of hyperthyroidism
      • these patients have a low pulse rate and a propensity to develop thyroid storm due to delay in diagnosis
    Signs and Symptoms
  • Pathophysiology Hyperthyroid state Precipitating factor Increase in thyroid hormone (shift from protein bound to free hormone) Sudden increase in metabolism End organ damage Exaggerated SSx of hyperthyroidism
  • Predisposing factors
    • Some causes that rapidly increase the thyroid hormone levels include the following:
      • Surgery, thyroidal or nonthyroidal
      • Radioiodine therapy
      • Withdrawal of antithyroid drug therapy
      • Vigorous thyroid palpation
      • Iodinated contrast dye
      • Thyroid hormone ingestion
    • Other common precipitants include the following:
      • Infection
      • Emotional stress
      • Tooth extraction
      • Diabetic ketoacidosis
      • Hypoglycemia
      • Trauma
      • Bowel infarction
      • Parturition
      • Toxemia of pregnancy
      • Pulmonary embolism
      • Cerebrovascular accident
      • Gestational trophoblastic disease
    Predisposing factors
  • Management
    • a multi-step process
    • ideal therapy:
      • block the synthesis, secretion, and peripheral action of the thyroid hormone
    • supportive therapy
      • aggressive
      • stabilize homeostasis
      • reverse multiorgan decompensation
    • identify and treat the precipitating factor
    • definitive treatment
      • avoid recurrence
    Management
    • Blocking Thyroid Hormone Synthesis
      • Antithyroid compounds propylthiouracil (PTU)
      • methimazole (MMI)
      • PTU also blocks peripheral conversion of T4 to T3 and hence is preferred in thyroid storm over MMI
      • PTU and MMI block the incorporation of iodine into thyroglobulin within 1 hour of ingestion
      • A history of hepatotoxicity or agranulocytosis from previous thioamide therapy precludes use of PTU and MMI
    Management
    • Blocking Thyroid Hormone Secretion
      • Lugol solution or saturated solution of potassium iodide
        • Iodine therapy should be administered after approximately 1 hour following administration of PTU or MMI
        • iodine used alone helps to increase thyroid hormone stores and may increase the thyrotoxic state.
      • lithium
        • intolerant to iodine
        • unable to take PTU or MMI
    Management
    • Blocking Peripheral Action of Thyroid Hormone
      • Propranolol
        • drug of choice to counter peripheral action of thyroid hormone.
        • blocks beta-adrenergic receptors
        • prevents conversion of T4 to T3
        • produces dramatic improvement in clinical status and greatly ameliorates symptoms
      • Esmolol
        • ultra-short-acting beta-blocking agent used successfully in thyrotoxicosis and thyroid storm
      • Guanethidine or reserpine
        • in patients with congestive cardiac failure, bronchospasm, or history of asthma.
    Management
    • Supportive Measures
      • Aggressive fluid and electrolyte therapy
        • needed for dehydration and hypotension
        • Fluid requirements may increase to 3-5 L/day
        • invasive monitoring is advisable
      • Pressor agents can be used when hypotension persists following adequate fluid replacement
    Management
    • Supportive Measures
      • Add glucose to IV fluids for nutritional support
      • Multivitamins, especially vitamin B-1, are added to prevent Wernicke encephalopathy
      • Hyperthermia is treated through central cooling and peripheral heat dissipation
        • Acetaminophen is the drug of choice
        • aspirin may displace thyroid hormone from binding sites and increase severity of thyroid storm
        • Cooling blankets, ice packs, and alcohol sponges encourage dissipation of heat
    Management
    • Supportive Measures
      • glucocorticoids
        • associated with improved survival rates
        • reduce iodine uptake
        • reduce antibody titers of thyroid-stimulating antibodies with stabilization of the vascular bed
        • stress dose of glucocorticoid (eg, hydrocortisone, dexamethasone) is routine
    Management
    • Supportive Measures
      • Digitalization
        • required to control the ventricular rate in patients with atrial fibrillation.
      • Anticoagulation drugs may be needed for atrial fibrillation and can be administered in the absence of contraindications
        • Digoxin
      • Congestive cardiac failure
        • may require Swan-Ganz catheter monitoring
    Management
  • Lab Studies
    • no specific diagnostic criteria to establish the diagnosis of thyroid storm exist
    • Burch and Wartofsky
      • constructed an excellent clinical diagnostic point scale to facilitate a semiquantitative distinction between uncomplicated thyrotoxicosis, impending storm, and established thyroid storm
      • Laboratory findings in thyroid storm are consistent with those of thyrotoxicosis and include the following:
        • Elevated T3 and T4 levels
        • Elevated T3 uptake
        • Suppressed TSH levels
        • Elevated 24-hour radioiodine uptake
    • Elevated T4 and decreased TSH are the only abnormal findings needed for confirmation of thyrotoxicosis
    • Treatment should not be withheld for any laboratory confirmation of hyperthyroidism when thyroid storm is suspected clinically
    • A 2-hour radioiodine uptake is advisable if thyroid storm is suspected and no past history of hyperthyroidism exists
    Lab Studies
    • Other abnormal laboratory values that point toward decompensation of homeostasis include the following:
      • Increased BUN and creatinine kinase
      • Electrolyte imbalance from dehydration, anemia, thrombocytopenia, and leukocytosis
      • Hepatocellular dysfunction as shown by elevated levels of transaminases, lactate dehydrogenase, alkaline phosphatase, and bilirubin
      • Elevated calcium levels
      • Hyperglycemia
    Lab Studies
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