Thyroid Storm


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Thyroid Storm signs and symptoms, management...

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Thyroid Storm

  2. 2. INTRODUCTION <ul><li>clinical manifestation of an extreme hyperthyroid state </li></ul><ul><ul><li>morbidity </li></ul></ul><ul><ul><li>disability </li></ul></ul><ul><ul><li>death </li></ul></ul>
  3. 3. thyroid storm <ul><li>Before </li></ul><ul><ul><li>common complication of toxic goiter surgery </li></ul></ul><ul><ul><li>intraoperative and postoperative </li></ul></ul><ul><li>Today </li></ul><ul><ul><li>more commonly seen in a thyrotoxic patient with intercurrent illness or surgical emergency </li></ul></ul><ul><ul><li>Untreated or inadequately treated patients </li></ul></ul>
  4. 4. <ul><li>Early recognition and prompt intervention are necessary to prevail in management of this phenomenon </li></ul>
  5. 5. Etiology <ul><li>Exact cause unknown </li></ul><ul><li>A precipitating factor usually is found with thyroid storm </li></ul><ul><ul><li>Stress (most common) </li></ul></ul><ul><ul><li>Concurrent illness e.g., sepsis </li></ul></ul><ul><ul><li>Surgical emergency </li></ul></ul>
  6. 6. <ul><li>thyroid storm can occur in </li></ul><ul><ul><li>Graves disease (more common) </li></ul></ul><ul><ul><li>toxic adenoma </li></ul></ul><ul><ul><li>multinodular toxic goiter </li></ul></ul>Etiology
  7. 7. Mortality/Morbidity <ul><li>fatal when untreated </li></ul><ul><li>mortality: 20-30% </li></ul>
  8. 8. 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
  9. 9. <ul><li>unusual presentations </li></ul><ul><ul><li>chest pain </li></ul></ul><ul><ul><li>acute abdomen </li></ul></ul><ul><ul><li>status epilepticus </li></ul></ul><ul><ul><li>stroke </li></ul></ul><ul><ul><li>acute renal failure due to rhabdomyolysis </li></ul></ul><ul><ul><li>apathetic thyroidism </li></ul></ul>Signs and Symptoms
  10. 10. <ul><li>apathetic thyroidism </li></ul><ul><ul><li>masked hyperthyroidism </li></ul></ul><ul><ul><li>first described by Lahey 60 years ago </li></ul></ul><ul><ul><li>present without goiter, ophthalmopathy, or prominent symptoms of hyperthyroidism </li></ul></ul><ul><ul><li>these patients have a low pulse rate and a propensity to develop thyroid storm due to delay in diagnosis </li></ul></ul>Signs and Symptoms
  11. 11. 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
  12. 12. Predisposing factors <ul><li>Some causes that rapidly increase the thyroid hormone levels include the following: </li></ul><ul><ul><li>Surgery, thyroidal or nonthyroidal </li></ul></ul><ul><ul><li>Radioiodine therapy </li></ul></ul><ul><ul><li>Withdrawal of antithyroid drug therapy </li></ul></ul><ul><ul><li>Vigorous thyroid palpation </li></ul></ul><ul><ul><li>Iodinated contrast dye </li></ul></ul><ul><ul><li>Thyroid hormone ingestion </li></ul></ul>
  13. 13. <ul><li>Other common precipitants include the following: </li></ul><ul><ul><li>Infection </li></ul></ul><ul><ul><li>Emotional stress </li></ul></ul><ul><ul><li>Tooth extraction </li></ul></ul><ul><ul><li>Diabetic ketoacidosis </li></ul></ul><ul><ul><li>Hypoglycemia </li></ul></ul><ul><ul><li>Trauma </li></ul></ul><ul><ul><li>Bowel infarction </li></ul></ul><ul><ul><li>Parturition </li></ul></ul><ul><ul><li>Toxemia of pregnancy </li></ul></ul><ul><ul><li>Pulmonary embolism </li></ul></ul><ul><ul><li>Cerebrovascular accident </li></ul></ul><ul><ul><li>Gestational trophoblastic disease </li></ul></ul>Predisposing factors
  14. 14. Management <ul><li>a multi-step process </li></ul><ul><li>ideal therapy: </li></ul><ul><ul><li>block the synthesis, secretion, and peripheral action of the thyroid hormone </li></ul></ul>
  15. 15. <ul><li>supportive therapy </li></ul><ul><ul><li>aggressive </li></ul></ul><ul><ul><li>stabilize homeostasis </li></ul></ul><ul><ul><li>reverse multiorgan decompensation </li></ul></ul><ul><li>identify and treat the precipitating factor </li></ul><ul><li>definitive treatment </li></ul><ul><ul><li>avoid recurrence </li></ul></ul>Management
  16. 16. <ul><li>Blocking Thyroid Hormone Synthesis </li></ul><ul><ul><li>Antithyroid compounds propylthiouracil (PTU) </li></ul></ul><ul><ul><li>methimazole (MMI) </li></ul></ul><ul><ul><li>PTU also blocks peripheral conversion of T4 to T3 and hence is preferred in thyroid storm over MMI </li></ul></ul><ul><ul><li>PTU and MMI block the incorporation of iodine into thyroglobulin within 1 hour of ingestion </li></ul></ul><ul><ul><li>A history of hepatotoxicity or agranulocytosis from previous thioamide therapy precludes use of PTU and MMI </li></ul></ul>Management
  17. 17. <ul><li>Blocking Thyroid Hormone Secretion </li></ul><ul><ul><li>Lugol solution or saturated solution of potassium iodide </li></ul></ul><ul><ul><ul><li>Iodine therapy should be administered after approximately 1 hour following administration of PTU or MMI </li></ul></ul></ul><ul><ul><ul><li>iodine used alone helps to increase thyroid hormone stores and may increase the thyrotoxic state. </li></ul></ul></ul><ul><ul><li>lithium </li></ul></ul><ul><ul><ul><li>intolerant to iodine </li></ul></ul></ul><ul><ul><ul><li>unable to take PTU or MMI </li></ul></ul></ul>Management
  18. 18. <ul><li>Blocking Peripheral Action of Thyroid Hormone </li></ul><ul><ul><li>Propranolol </li></ul></ul><ul><ul><ul><li>drug of choice to counter peripheral action of thyroid hormone. </li></ul></ul></ul><ul><ul><ul><li>blocks beta-adrenergic receptors </li></ul></ul></ul><ul><ul><ul><li>prevents conversion of T4 to T3 </li></ul></ul></ul><ul><ul><ul><li>produces dramatic improvement in clinical status and greatly ameliorates symptoms </li></ul></ul></ul><ul><ul><li>Esmolol </li></ul></ul><ul><ul><ul><li>ultra-short-acting beta-blocking agent used successfully in thyrotoxicosis and thyroid storm </li></ul></ul></ul><ul><ul><li>Guanethidine or reserpine </li></ul></ul><ul><ul><ul><li>in patients with congestive cardiac failure, bronchospasm, or history of asthma. </li></ul></ul></ul>Management
  19. 19. <ul><li>Supportive Measures </li></ul><ul><ul><li>Aggressive fluid and electrolyte therapy </li></ul></ul><ul><ul><ul><li>needed for dehydration and hypotension </li></ul></ul></ul><ul><ul><ul><li>Fluid requirements may increase to 3-5 L/day </li></ul></ul></ul><ul><ul><ul><li>invasive monitoring is advisable </li></ul></ul></ul><ul><ul><li>Pressor agents can be used when hypotension persists following adequate fluid replacement </li></ul></ul>Management
  20. 20. <ul><li>Supportive Measures </li></ul><ul><ul><li>Add glucose to IV fluids for nutritional support </li></ul></ul><ul><ul><li>Multivitamins, especially vitamin B-1, are added to prevent Wernicke encephalopathy </li></ul></ul><ul><ul><li>Hyperthermia is treated through central cooling and peripheral heat dissipation </li></ul></ul><ul><ul><ul><li>Acetaminophen is the drug of choice </li></ul></ul></ul><ul><ul><ul><li>aspirin may displace thyroid hormone from binding sites and increase severity of thyroid storm </li></ul></ul></ul><ul><ul><ul><li>Cooling blankets, ice packs, and alcohol sponges encourage dissipation of heat </li></ul></ul></ul>Management
  21. 21. <ul><li>Supportive Measures </li></ul><ul><ul><li>glucocorticoids </li></ul></ul><ul><ul><ul><li>associated with improved survival rates </li></ul></ul></ul><ul><ul><ul><li>reduce iodine uptake </li></ul></ul></ul><ul><ul><ul><li>reduce antibody titers of thyroid-stimulating antibodies with stabilization of the vascular bed </li></ul></ul></ul><ul><ul><ul><li>stress dose of glucocorticoid (eg, hydrocortisone, dexamethasone) is routine </li></ul></ul></ul>Management
  22. 22. <ul><li>Supportive Measures </li></ul><ul><ul><li>Digitalization </li></ul></ul><ul><ul><ul><li>required to control the ventricular rate in patients with atrial fibrillation. </li></ul></ul></ul><ul><ul><li>Anticoagulation drugs may be needed for atrial fibrillation and can be administered in the absence of contraindications </li></ul></ul><ul><ul><ul><li>Digoxin </li></ul></ul></ul><ul><ul><li>Congestive cardiac failure </li></ul></ul><ul><ul><ul><li>may require Swan-Ganz catheter monitoring </li></ul></ul></ul>Management
  23. 23. Lab Studies <ul><li>no specific diagnostic criteria to establish the diagnosis of thyroid storm exist </li></ul><ul><li>Burch and Wartofsky </li></ul><ul><ul><li>constructed an excellent clinical diagnostic point scale to facilitate a semiquantitative distinction between uncomplicated thyrotoxicosis, impending storm, and established thyroid storm </li></ul></ul><ul><ul><li>Laboratory findings in thyroid storm are consistent with those of thyrotoxicosis and include the following: </li></ul></ul><ul><ul><ul><li>Elevated T3 and T4 levels </li></ul></ul></ul><ul><ul><ul><li>Elevated T3 uptake </li></ul></ul></ul><ul><ul><ul><li>Suppressed TSH levels </li></ul></ul></ul><ul><ul><ul><li>Elevated 24-hour radioiodine uptake </li></ul></ul></ul>
  24. 24. <ul><li>Elevated T4 and decreased TSH are the only abnormal findings needed for confirmation of thyrotoxicosis </li></ul><ul><li>Treatment should not be withheld for any laboratory confirmation of hyperthyroidism when thyroid storm is suspected clinically </li></ul><ul><li>A 2-hour radioiodine uptake is advisable if thyroid storm is suspected and no past history of hyperthyroidism exists </li></ul>Lab Studies
  25. 25. <ul><li>Other abnormal laboratory values that point toward decompensation of homeostasis include the following: </li></ul><ul><ul><li>Increased BUN and creatinine kinase </li></ul></ul><ul><ul><li>Electrolyte imbalance from dehydration, anemia, thrombocytopenia, and leukocytosis </li></ul></ul><ul><ul><li>Hepatocellular dysfunction as shown by elevated levels of transaminases, lactate dehydrogenase, alkaline phosphatase, and bilirubin </li></ul></ul><ul><ul><li>Elevated calcium levels </li></ul></ul><ul><ul><li>Hyperglycemia </li></ul></ul>Lab Studies
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