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Hyperthyroidism and Thyroid Storm Tintinalli Chapter 215 12/15/05 Prepared by Trent W. Smith Lecture by Dr. Klien MD
Normal Thyroid State <ul><li>Synthesis and release of thyroid hormone is controlled by TSH relaesed form the anterior pitu...
Normal Thyroid State <ul><li>Thyroid hormone is reversible bound to various proteins including thyronine-binding globulin ...
Hyperthyroidism <ul><li>Occurs in in all ages  </li></ul><ul><ul><li>Uncommon under the age of 15 </li></ul></ul><ul><li>1...
Hyperthyroidism <ul><li>Toxic multinodular and toxic nodular goiters are the next most common etiologies </li></ul><ul><ul...
Hyperthyroidism <ul><li>Amiodarone-induced thyrotoxicosis (AIT) </li></ul><ul><ul><li>Amiodarone is iodine rich and may ca...
Hyperthyroidism <ul><li>Hyperthyroidism resembles a state of increased adrenergic activity despite a normal or low serum c...
Hyperthyroidism Warm moist skin Palpitations Hyperreflexia Weight loss Tachycardia/arrhythmia Hyperdefication Systolic hyp...
Hyperthyroidism <ul><li>Confirmed by thyroid function test </li></ul><ul><ul><li>Elevated free T4 and Low TSH </li></ul></...
Hyperthyroidism <ul><li>Treatment </li></ul><ul><ul><li>Palliative treatment of mild hyperthyroidism is accomplished using...
Hyperthyroidism <ul><li>Treatment cont. </li></ul><ul><ul><li>Toxic multinodular goiter and solitary adenomas may be treat...
Thyroid Storm <ul><li>A life threatening hypremetabolic state due to hyperthyroidism </li></ul><ul><li>Mortality rate is h...
Thyroid Storm <ul><li>Preciptatnts of Thyroid Storm  (tabel 215-4) </li></ul>Withdrawal of thyroid med Surgery Palpation o...
Thyroid Storm <ul><li>Clinical features </li></ul><ul><ul><li>The  most common signs  are fever, tachycardia out of propor...
Thyroid Storm <ul><li>Clinical features cont. </li></ul><ul><ul><li>Common GI symptoms include diarrhea and hyperdeficatio...
Thyroid Storm <ul><li>Diagnosis </li></ul><ul><ul><li>Thyroid storm is a clinical diagnosis based upon suspicion and treat...
Thyroid Storm <ul><li>Treatment </li></ul><ul><ul><li>Initial stabilization includes airway protection, oxygenation, fluid...
Thyroid Storm <ul><li>Drug  Treatment of Thyroid Storm   (table 216-6) </li></ul><ul><ul><li>Decrease de novo synthesis: <...
Thyroid Storm <ul><li>Treatment cont </li></ul><ul><ul><li>Propranolol has the additional effects or blocking perpheral co...
Thyroid Storm <ul><li>Disposition </li></ul><ul><ul><li>Admit to the ICU  </li></ul></ul>
Hypothyroidism and Myxedeam Coma Tintinalli Chapter 215 12/15/05 Prepared by Trent W. Smith Lecture by Dr. Klien MD
Hypothyroidism <ul><li>Occurs when there is insufficient hormone production or secretion </li></ul><ul><li>Occurs more fre...
Hypothyroidism <ul><li>Etiologies of Hypothyroidism  </li></ul><ul><ul><li>Primary </li></ul></ul><ul><ul><ul><li>Autoimmu...
Hypothyroidism <ul><li>Etiologies of Hypothyroidism </li></ul><ul><ul><li>Post Partum </li></ul></ul><ul><ul><ul><li>Occur...
Hypothyroidism <ul><li>Etiologies of Hypothyroidism  </li></ul><ul><ul><li>Drugs </li></ul></ul><ul><ul><ul><li>Amiodarone...
Hypothyroidism <ul><li>Clinical Features </li></ul><ul><ul><li>The  typical symptoms  of hypothyroidism include fatigue, w...
Hypothyroidism <ul><li>Clinical Features cont. </li></ul><ul><ul><li>Cardiac findings include bradycardia, enlarged heart,...
Hypothyroidism <ul><li>Symptoms and Signs or Hypothyroidism  (table 216-2) </li></ul>Periobital puffiness Cold intolerance...
Hypothyroidism <ul><li>Treatment </li></ul><ul><ul><li>Most patient with uncomplicated symptomatic Hypothyroidism may be r...
Myxedema <ul><li>Myxedema is a rare life threatening decompensation of hypothyroidism </li></ul><ul><ul><li>Usually in ind...
Myxedema <ul><li>Precipitating events include </li></ul><ul><ul><li>Infection </li></ul></ul><ul><ul><li>CHF </li></ul></u...
Myxedema <ul><li>In addition to the clinical features of hypothyroidism  patients may present with </li></ul><ul><ul><li>H...
Myxedema <ul><li>Diagnosis </li></ul><ul><ul><li>Must have high clinical suspicion </li></ul></ul><ul><ul><li>Commonly has...
Myxedema <ul><li>Diagnosis cont </li></ul><ul><ul><li>Laboratory evaluation may reveal </li></ul></ul><ul><ul><ul><li>Anem...
Myxedema <ul><li>Diagnosis cont. </li></ul><ul><ul><li>EKG may reveal </li></ul></ul><ul><ul><ul><li>Sinus Bradycardia </l...
Myxedema <ul><li>Treatment  (see table 216-5 below) </li></ul><ul><ul><li>No prospective studies on optimal therapy have b...
Myxedema <ul><li>Treatment cont. </li></ul><ul><ul><li>Hyponatremia typically responds to fluid restrictions. Severe cases...
Myxedema <ul><li>Treatment cont. </li></ul><ul><ul><li>L-triiodothyronine 25 mcg IV or orally q 8 h is a alternative </li>...
Myxedema <ul><li>Treatment of Myxedema Coma (table 216-5) </li></ul><ul><li>Recognition </li></ul><ul><li>Supportive thera...
Myxedema <ul><li>Disposition </li></ul><ul><ul><li>Admit to appropiately monitored bed </li></ul></ul>
Questions <ul><li>1.  Hyperthyroidism is Characterized by which of the following </li></ul><ul><ul><li>A. Fatigue </li></u...
<ul><li>2.  The most common etiology of hyperthyroidism is </li></ul><ul><ul><li>A. Toxic Multinodular </li></ul></ul><ul>...
<ul><li>3.  Typical Feature of Hyperthyroidism include </li></ul><ul><ul><li>A. Fatigue </li></ul></ul><ul><ul><li>B. Weak...
<ul><li>4. T or F Hyperthyroidism is more common in women </li></ul><ul><li>5. T or F Hypothyroidism is more common in wom...
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  1. 1. Hyperthyroidism and Thyroid Storm Tintinalli Chapter 215 12/15/05 Prepared by Trent W. Smith Lecture by Dr. Klien MD
  2. 2. Normal Thyroid State <ul><li>Synthesis and release of thyroid hormone is controlled by TSH relaesed form the anterior pituitary </li></ul><ul><li>TSH is controlled by the release of thyroid releasing hormone (TRH) from the hypothalmus and a negative feedback loop to the pituitary </li></ul><ul><li>Thyroid hormone production s dependent on adequate adequate iodine intake </li></ul>
  3. 3. Normal Thyroid State <ul><li>Thyroid hormone is reversible bound to various proteins including thyronine-binding globulin (TBG) </li></ul><ul><li>Free unbound portions are biologically active </li></ul><ul><li>T4 is the predominant circulating hormone </li></ul><ul><li>T4 is deiodinated to t3 </li></ul><ul><li>T3 is biologically more active than T4 but has a shorter half-life </li></ul>
  4. 4. Hyperthyroidism <ul><li>Occurs in in all ages </li></ul><ul><ul><li>Uncommon under the age of 15 </li></ul></ul><ul><li>10 x’s more common in women (1/10,000) </li></ul><ul><li>Graves disease is the most common etiology </li></ul><ul><ul><li>80% of cases in the U.S. </li></ul></ul><ul><ul><li>Common in the 3 rd and 4 th decades </li></ul></ul><ul><ul><li>Caused by autoimmune thyroid-stimulating antibodies </li></ul></ul><ul><ul><li>Associated with diffuse goiter, opthalmopathy, and local dermopathy </li></ul></ul>
  5. 5. Hyperthyroidism <ul><li>Toxic multinodular and toxic nodular goiters are the next most common etiologies </li></ul><ul><ul><li>Usually occurs in older populations </li></ul></ul><ul><ul><li>Commonly with previous history of goiter </li></ul></ul><ul><ul><li>Often with milder symptoms of thyrotoxicosis </li></ul></ul>
  6. 6. Hyperthyroidism <ul><li>Amiodarone-induced thyrotoxicosis (AIT) </li></ul><ul><ul><li>Amiodarone is iodine rich and may cause both hyper and hypothyroidism </li></ul></ul><ul><ul><li>Difficult to treat because of incomplete understanding of mechanism </li></ul></ul><ul><ul><li>Two major forms exists </li></ul></ul><ul><ul><ul><li>Type 1 occurs with a normal thyroid </li></ul></ul></ul><ul><ul><ul><li>Type 2 occurs with a abnormal thyroid </li></ul></ul></ul><ul><ul><li>Tx. Varies based on the the type </li></ul></ul>
  7. 7. Hyperthyroidism <ul><li>Hyperthyroidism resembles a state of increased adrenergic activity despite a normal or low serum cortisol level </li></ul><ul><li>Classic complaints include heat intolerance, palpitations, weight loss, sweating, nervousness, and fatigue </li></ul>
  8. 8. Hyperthyroidism Warm moist skin Palpitations Hyperreflexia Weight loss Tachycardia/arrhythmia Hyperdefication Systolic hypertension Dyspnea Widened pulse pressure Menstrual abnormalities Tremor Tremors Lid retraction/stare Nervousness Hyperkinesis Fatigue Goiter/thyroid burit Weaknes Lid lag Increased sweating Opthalmopathy Heat intolerance Signs Symptoms
  9. 9. Hyperthyroidism <ul><li>Confirmed by thyroid function test </li></ul><ul><ul><li>Elevated free T4 and Low TSH </li></ul></ul><ul><ul><li>In some cases of graves disease T4 may be normal and TSH decreased but the patient appears thyrotoxic </li></ul></ul><ul><ul><li>T3 level should be done to rule out T3 toxicosis </li></ul></ul><ul><ul><li>Hypothyroidism secondary to pituitary adenoma will have elevated TSH levels </li></ul></ul>
  10. 10. Hyperthyroidism <ul><li>Treatment </li></ul><ul><ul><li>Palliative treatment of mild hyperthyroidism is accomplished using B-blockers </li></ul></ul><ul><ul><ul><li>Most commonly used is propanolol </li></ul></ul></ul><ul><ul><li>Treatment of Graves diseases include long-term use of antithyroid medications, radioactive iodine, or subtotal thyroidectomy </li></ul></ul><ul><ul><li>Type I AIT is treated with methimazole and potassium perchlorate </li></ul></ul><ul><ul><li>Type II AIT is treated with glucocorticoids </li></ul></ul>
  11. 11. Hyperthyroidism <ul><li>Treatment cont. </li></ul><ul><ul><li>Toxic multinodular goiter and solitary adenomas may be treated with radioiodine therapy </li></ul></ul><ul><ul><li>Thryoiditis is usually self limited and therapy is rarely needed </li></ul></ul>
  12. 12. Thyroid Storm <ul><li>A life threatening hypremetabolic state due to hyperthyroidism </li></ul><ul><li>Mortality rate is high (10-75%) despite treatment </li></ul><ul><li>Usually occurs as a result of previously unrecognized or poorly treated hyperthyroidism </li></ul><ul><li>Thyroid hormone levels do not help to differentiate between uncomplicated hyperthyroidism and thyroid storm </li></ul>
  13. 13. Thyroid Storm <ul><li>Preciptatnts of Thyroid Storm (tabel 215-4) </li></ul>Withdrawal of thyroid med Surgery Palpation of thyroid gland Iodine administration Unknown etiology (20-25%) Ingestion of thyroid hormone PE CVA MI DKA Trauma Infection
  14. 14. Thyroid Storm <ul><li>Clinical features </li></ul><ul><ul><li>The most common signs are fever, tachycardia out of proportion to the fever, altered mental status, and diaphoresis </li></ul></ul><ul><ul><li>Clues include a history of hyperthyroidism, exophthalmoses, widened pulse pressure and a palpable goiter </li></ul></ul><ul><ul><li>Patients may present with signs of CHF </li></ul></ul>
  15. 15. Thyroid Storm <ul><li>Clinical features cont. </li></ul><ul><ul><li>Common GI symptoms include diarrhea and hyperdefication </li></ul></ul><ul><ul><li>Apathetic thyrotoxicosis is a distinct presentation seen in the elderly </li></ul></ul><ul><ul><ul><li>Characteristic symptoms include lethargy, slowed mentation, and apathetic facies </li></ul></ul></ul><ul><ul><ul><li>Goiter, weight loss , and proximal muscle weakness also present </li></ul></ul></ul>
  16. 16. Thyroid Storm <ul><li>Diagnosis </li></ul><ul><ul><li>Thyroid storm is a clinical diagnosis based upon suspicion and treated empirically </li></ul></ul><ul><ul><li>Lab work is non specific and may include Leukocytosis, hyperglycemia, elevated transaminase and elevated bilirubin </li></ul></ul>
  17. 17. Thyroid Storm <ul><li>Treatment </li></ul><ul><ul><li>Initial stabilization includes airway protection, oxygenation, fluids and cardiac monitoring </li></ul></ul><ul><ul><li>Treatment can then be divided into 5 areas: </li></ul></ul><ul><ul><ul><li>General supportive care </li></ul></ul></ul><ul><ul><ul><li>Inhibition of thyroid hormone synthesis </li></ul></ul></ul><ul><ul><ul><li>Retardation of thyroid hormone release </li></ul></ul></ul><ul><ul><ul><li>Blockade of peripheral thyroid hormone effects </li></ul></ul></ul><ul><ul><ul><li>Identification and treatment of precipitating events </li></ul></ul></ul>
  18. 18. Thyroid Storm <ul><li>Drug Treatment of Thyroid Storm (table 216-6) </li></ul><ul><ul><li>Decrease de novo synthesis: </li></ul></ul><ul><ul><ul><li>Porpythiouracil 600-1000mg PO initially, followed by 200-250 mg q 4 hrs </li></ul></ul></ul><ul><ul><ul><li>Methimazole 40 mg PO initial dose, then 25 mg PO q6h </li></ul></ul></ul><ul><ul><li>Prevent relases of hormone (after synthesis blockade intiated) </li></ul></ul><ul><ul><ul><li>Iodine Iaponoric acid (Telepaque) 1 gm IV q8h for the first 24 h, then 500 mg bid or Potassium iodide (SSKI) 5 drops PO q6h or Lugol solution 8-10 drops PO q6h </li></ul></ul></ul><ul><ul><ul><li>Lithuim 800-1200 mg PO every day </li></ul></ul></ul><ul><ul><li>Prevent peripheral effects: </li></ul></ul><ul><ul><ul><li>B-Blocker Propanolol (IV) titrate 1-2 mg q 5min prn (may need 240-480mg PO q day) or Esmolol (IV) 500 mcg/kg IV bolus, then 50-200 mcg/kg per min maintenance </li></ul></ul></ul><ul><ul><ul><li>Guanethidine 30-40 mg PO q 6 h </li></ul></ul></ul><ul><ul><ul><li>Reserpine 2.5-5 mg IM q4-6h </li></ul></ul></ul><ul><li>Other consideration: </li></ul><ul><ul><ul><li>Corticosteroids Hydrocortisone 100 mg IV q 8 h or dexamethosone 2 mg IV q 6 hr </li></ul></ul></ul><ul><ul><ul><li>Antipyretics Cooling blanket acteaminophen 650 mg PO q 4-6h </li></ul></ul></ul>
  19. 19. Thyroid Storm <ul><li>Treatment cont </li></ul><ul><ul><li>Propranolol has the additional effects or blocking perpheral conversion of T4-T3 </li></ul></ul><ul><ul><li>Avoid Salicylates because it may displace T4 from TBG </li></ul></ul><ul><ul><li>If the patient continues to deteriorate despite appropriate therapy circulating thyroid hormone may be removed by plasma transfusion, plasmapheresis, charchoal plasmaperfusion </li></ul></ul><ul><ul><li>Remember you must not administer iodine until the synthetic pathway has been blocked </li></ul></ul>
  20. 20. Thyroid Storm <ul><li>Disposition </li></ul><ul><ul><li>Admit to the ICU </li></ul></ul>
  21. 21. Hypothyroidism and Myxedeam Coma Tintinalli Chapter 215 12/15/05 Prepared by Trent W. Smith Lecture by Dr. Klien MD
  22. 22. Hypothyroidism <ul><li>Occurs when there is insufficient hormone production or secretion </li></ul><ul><li>Occurs more frequently in women (0.6 to 5.9 %) </li></ul><ul><li>The most common etiologies are </li></ul><ul><ul><li>Primary thyroid failure due to autoimmune diseases (Hashimoto thyroiditis is the most common) </li></ul></ul><ul><ul><li>Idiopathic causes </li></ul></ul><ul><ul><li>Ablative therapy </li></ul></ul><ul><ul><li>Iodine deficiency </li></ul></ul><ul><li>May be transient </li></ul><ul><ul><li>Pathophysiology is unclear but may be viral in nature </li></ul></ul>
  23. 23. Hypothyroidism <ul><li>Etiologies of Hypothyroidism </li></ul><ul><ul><li>Primary </li></ul></ul><ul><ul><ul><li>Autoimmune etiologies </li></ul></ul></ul><ul><ul><ul><ul><li>Hashimotos is the most common </li></ul></ul></ul></ul><ul><ul><ul><li>Idopathic </li></ul></ul></ul><ul><ul><ul><li>Post ablation (surgical, radioiodine) </li></ul></ul></ul><ul><ul><ul><li>Post external radiation </li></ul></ul></ul><ul><ul><ul><li>Thryoiditis (subacute, silent, postpartum) </li></ul></ul></ul><ul><ul><ul><ul><li>Postpartum thyroiditis occurs within 3-6 months and occurs in 2- 16 % of women </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Self limited etiologies, often prededed by hyperthroid phase </li></ul></ul></ul></ul><ul><ul><ul><li>Infiltrative disease (lymphoma, sarcoid, amyloidosis, Tuberculosis </li></ul></ul></ul><ul><ul><ul><li>Congenital </li></ul></ul></ul>
  24. 24. Hypothyroidism <ul><li>Etiologies of Hypothyroidism </li></ul><ul><ul><li>Post Partum </li></ul></ul><ul><ul><ul><li>Occurs 3-6 months post partum and occurs in 2-16% of women </li></ul></ul></ul><ul><ul><li>Secondary (pituitary) </li></ul></ul><ul><ul><ul><li>Neoplasm </li></ul></ul></ul><ul><ul><ul><li>Infiltrative Dz. </li></ul></ul></ul><ul><ul><ul><li>Hemorrhage </li></ul></ul></ul><ul><ul><li>Tertiary (hypothalamic) </li></ul></ul><ul><ul><ul><li>Neoplasm </li></ul></ul></ul><ul><ul><ul><li>Infiltrative Dz. </li></ul></ul></ul>
  25. 25. Hypothyroidism <ul><li>Etiologies of Hypothyroidism </li></ul><ul><ul><li>Drugs </li></ul></ul><ul><ul><ul><li>Amiodarone </li></ul></ul></ul><ul><ul><ul><ul><li>Occurs in 1-32% of patients </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Most likely due to the large amount of iodine released in the metabolism of the drug which inhibits thyroid hormone synthesis, release, and conversion of T4 to T3 </li></ul></ul></ul></ul><ul><ul><ul><li>Lithium </li></ul></ul></ul><ul><ul><ul><ul><li>Acts similarly to iodine and inhibit thyroid hormone release </li></ul></ul></ul></ul><ul><ul><ul><li>Iodine (in patients with pre-existing autoimmune disease) </li></ul></ul></ul><ul><ul><ul><li>Antithyroid medication </li></ul></ul></ul>
  26. 26. Hypothyroidism <ul><li>Clinical Features </li></ul><ul><ul><li>The typical symptoms of hypothyroidism include fatigue, weakness, cold intolerance, constipation, weight gain, and deepening of voice. </li></ul></ul><ul><ul><li>Cautaneous signs include dry, scaly, yellow skin, non-pitting, waxy edema of the face and extremities (myxedema): and thinning eyebrows </li></ul></ul>
  27. 27. Hypothyroidism <ul><li>Clinical Features cont. </li></ul><ul><ul><li>Cardiac findings include bradycardia, enlarged heart, and low-voltage electrocardiogram </li></ul></ul><ul><ul><li>Paresthesia, ataxia, and prolongation or DTR’s are characteristic neurologic findings </li></ul></ul><ul><ul><li>See table below for more complete list </li></ul></ul>
  28. 28. Hypothyroidism <ul><li>Symptoms and Signs or Hypothyroidism (table 216-2) </li></ul>Periobital puffiness Cold intolerance Delayed relaxation of ankle jerks Depression Nonpitting edema Joint Pain Cool, rough, dry skin Constipation Hypothermia Weight Gain Loss of outer third of eyebrow Menstrual irregularities Peripheral Neuropathy Infertility Bracycardia Muscle cramps Hoarseness Fatigue Signs Symptoms
  29. 29. Hypothyroidism <ul><li>Treatment </li></ul><ul><ul><li>Most patient with uncomplicated symptomatic Hypothyroidism may be referred to the primary physician for further evaluation and initiation of treatment </li></ul></ul><ul><ul><li>If hypothyroidism is due to a secondary etiology initiation of thyroid hormone therapy may exacerbate preexisting adrenal insufficiency </li></ul></ul>
  30. 30. Myxedema <ul><li>Myxedema is a rare life threatening decompensation of hypothyroidism </li></ul><ul><ul><li>Usually in individuals with long-standing hypothyroidism </li></ul></ul><ul><ul><li>Most often seen in the winter months </li></ul></ul><ul><ul><li>More common in elderly women with underdiagnosed or undertreated hypothyroidism </li></ul></ul>
  31. 31. Myxedema <ul><li>Precipitating events include </li></ul><ul><ul><li>Infection </li></ul></ul><ul><ul><li>CHF </li></ul></ul><ul><ul><li>Trauma </li></ul></ul><ul><ul><li>CVA </li></ul></ul><ul><ul><li>Exposure to cold </li></ul></ul><ul><ul><li>Drugs </li></ul></ul><ul><ul><ul><li>Sedatives </li></ul></ul></ul><ul><ul><ul><li>Lithium </li></ul></ul></ul><ul><ul><ul><li>Amiodarone </li></ul></ul></ul>
  32. 32. Myxedema <ul><li>In addition to the clinical features of hypothyroidism patients may present with </li></ul><ul><ul><li>Hypothermia </li></ul></ul><ul><ul><li>Altered metal status </li></ul></ul><ul><ul><ul><li>Coma, delusions, and psychosis (myxedema maddness) </li></ul></ul></ul><ul><ul><li>Hyponatremia </li></ul></ul><ul><ul><ul><li>Dilutional secondary to decreased free-water clearance </li></ul></ul></ul><ul><ul><li>Hypoglycemia </li></ul></ul><ul><ul><ul><li>Secondary to impaired gluconeogenesis </li></ul></ul></ul><ul><ul><li>Hypotension </li></ul></ul><ul><ul><li>Bradycardia </li></ul></ul><ul><ul><li>Respiratory Failure </li></ul></ul><ul><ul><ul><li>Secondary to decreased strength of respiratory muscle </li></ul></ul></ul><ul><ul><ul><li>Hypercapnia and hypoxia is common </li></ul></ul></ul>
  33. 33. Myxedema <ul><li>Diagnosis </li></ul><ul><ul><li>Must have high clinical suspicion </li></ul></ul><ul><ul><li>Commonly has Hx. Of hypothyroidism </li></ul></ul><ul><ul><li>Delcine in function is usually insidious in onset </li></ul></ul>
  34. 34. Myxedema <ul><li>Diagnosis cont </li></ul><ul><ul><li>Laboratory evaluation may reveal </li></ul></ul><ul><ul><ul><li>Anemia </li></ul></ul></ul><ul><ul><ul><li>Hyponatremia </li></ul></ul></ul><ul><ul><ul><li>Hypoglycemia </li></ul></ul></ul><ul><ul><ul><li>↑ Transaminases </li></ul></ul></ul><ul><ul><ul><li>↑ CPK </li></ul></ul></ul><ul><ul><ul><li>↑ LDH </li></ul></ul></ul><ul><ul><ul><li>↓ Po2 and ↑PCo2 on ABG’s </li></ul></ul></ul>
  35. 35. Myxedema <ul><li>Diagnosis cont. </li></ul><ul><ul><li>EKG may reveal </li></ul></ul><ul><ul><ul><li>Sinus Bradycardia </li></ul></ul></ul><ul><ul><ul><li>Prolonged QT interval </li></ul></ul></ul><ul><ul><ul><li>Low voltage </li></ul></ul></ul><ul><ul><ul><li>Flattened or inverted T waves </li></ul></ul></ul>
  36. 36. Myxedema <ul><li>Treatment (see table 216-5 below) </li></ul><ul><ul><li>No prospective studies on optimal therapy have been done thus treatment recommendations are not uniform </li></ul></ul><ul><ul><li>Airway stabilization with adequate oxygenation and ventilation or vital </li></ul></ul><ul><ul><li>Cardiovascular status must be monitored closely </li></ul></ul><ul><ul><li>Hypothermic patients should be gradually rewarmed with gentle passive external rewarming </li></ul></ul><ul><ul><ul><li>Hypotension from reversal of hypothermic vasoconstriction should be avoided </li></ul></ul></ul>
  37. 37. Myxedema <ul><li>Treatment cont. </li></ul><ul><ul><li>Hyponatremia typically responds to fluid restrictions. Severe cases may require hypertonic saline with lasixs </li></ul></ul><ul><ul><li>Vasopressors are usually ineffective and should only be used in severe hypotension </li></ul></ul><ul><ul><li>Lovothyroxine 300-500 mcg slow IVP followed by 50-100 mcg daily </li></ul></ul>
  38. 38. Myxedema <ul><li>Treatment cont. </li></ul><ul><ul><li>L-triiodothyronine 25 mcg IV or orally q 8 h is a alternative </li></ul></ul><ul><ul><ul><li>This dose should be halved in patients with cardiovascular disease </li></ul></ul></ul><ul><ul><li>Hydrocortisone 100 mg IV q 8 hours should be given </li></ul></ul><ul><ul><ul><li>Send baseline cortisol level to lab if possible </li></ul></ul></ul><ul><ul><li>Precipitating causes should be sought and treated </li></ul></ul>
  39. 39. Myxedema <ul><li>Treatment of Myxedema Coma (table 216-5) </li></ul><ul><li>Recognition </li></ul><ul><li>Supportive therapy including ventilatory support </li></ul><ul><li>Thyroid replacement </li></ul><ul><ul><li>Lovothyroxine 300-500 mcg slow IVP followed by 50-100 mcg daily or </li></ul></ul><ul><ul><li>T3 25 mcg IV or PO q 8 hrs </li></ul></ul><ul><li>Glucocorticoid </li></ul><ul><ul><li>Hydrocortisone: 100 mg IV q8h </li></ul></ul><ul><li>Hypothermia </li></ul><ul><ul><li>Prevent additional loss </li></ul></ul><ul><ul><li>Passive external rewarming </li></ul></ul><ul><li>Electrolyte correction </li></ul><ul><ul><li>Gentle fluid restriction for dilutional hyponatremia </li></ul></ul><ul><ul><li>Hypertonic saline for severe hyponatremia </li></ul></ul><ul><li>Hypoglycemia </li></ul><ul><ul><li>Dextrose-containing IV fluids </li></ul></ul><ul><ul><li>Monitoring </li></ul></ul><ul><li>Aggressive treatment of presipitating causes </li></ul><ul><li>Admit patient to a monitored setting </li></ul>
  40. 40. Myxedema <ul><li>Disposition </li></ul><ul><ul><li>Admit to appropiately monitored bed </li></ul></ul>
  41. 41. Questions <ul><li>1. Hyperthyroidism is Characterized by which of the following </li></ul><ul><ul><li>A. Fatigue </li></ul></ul><ul><ul><li>B. Palpitations </li></ul></ul><ul><ul><li>C. Weight Loss </li></ul></ul><ul><ul><li>D. Heat intolerance </li></ul></ul><ul><ul><li>E. All the above </li></ul></ul>
  42. 42. <ul><li>2. The most common etiology of hyperthyroidism is </li></ul><ul><ul><li>A. Toxic Multinodular </li></ul></ul><ul><ul><li>B. Graves </li></ul></ul><ul><ul><li>C. Toxic Nodular </li></ul></ul><ul><ul><li>D. Amiodarone induces </li></ul></ul>
  43. 43. <ul><li>3. Typical Feature of Hyperthyroidism include </li></ul><ul><ul><li>A. Fatigue </li></ul></ul><ul><ul><li>B. Weakness </li></ul></ul><ul><ul><li>C. Constipation </li></ul></ul><ul><ul><li>E. Cold Intolerance </li></ul></ul><ul><ul><li>F. All the above </li></ul></ul>
  44. 44. <ul><li>4. T or F Hyperthyroidism is more common in women </li></ul><ul><li>5. T or F Hypothyroidism is more common in women </li></ul><ul><li>6. T or F Mild hyperthyroidism may be treated with B-blockers </li></ul><ul><li>Answers 1. E 2. B 3. F 4.T 5.T 6.T </li></ul>
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