Thyroid storm is basically a life threatening acute exacerbation of the clinical features of thyrotoxicosis.
Thyroid storm also known as thyroid crisis is an acute, life threatening hypermetabolic state induced by excessive activity of thyroid hormones in individuals with thyrotoxicosis.
Exact pathogenesis not understood.
No clear cut clinical feature separation from thyrotoxicosis.
precipitants of thyroid storm include the following
Infection, especially pneumonia
Cerebrovascular accident
Acute coronary syndrome, Congestive heart failure
Pulmonary embolus
Diabetic ketoacidosis
Parturition / toxemia
Major trauma
Surgery
Iodine 131 Rx or iodine contrast agents
Rapid withdrawl of antithyroid medications
Although the exact pathogenesis of thyroid storm is not fully understood, the following theories have been proposed:
Patients with thyroid storm reportedly have relatively higher levels of free THs than patients with uncomplicated thyrotoxicosis, although total TH levels may not be increased.
Adrenergic receptor activation is another hypothesis. Sympathetic nerves innervate the thyroid gland, and catecholamines stimulate TH synthesis. In turn, increased THs increase the density of beta-adrenergic receptors, thereby enhancing the effect of catecholamines.
The dramatic response of thyroid storm to beta-blockers and the precipitation of thyroid storm after accidental ingestion of adrenergic drugs such as pseudoephedrine support this theory. This theory also explains normal or low plasma levels and urinary excretion rates of catecholamines.
However, it does not explain why beta-blockers fail to decrease TH levels in thyrotoxicosis.
Another theory suggests a rapid rise of hormone levels as the pathogenic source. A drop in binding protein levels, which may occur postoperatively, might cause a sudden rise in free hormone levels. In addition, hormone levels may rise rapidly when the gland is manipulated during surgery, during vigorous palpation during examination, or from damaged follicles following RAI therapy.
Other proposed theories include alterations in tissue tolerance to THs, the presence of a unique catecholaminelike substance in thyrotoxicosis, and a direct sympathomimetic effect of TH as a result of its structural similarity to catecholamines.
General symptoms
Fever
Profuse sweating
Poor feeding and weight loss
Respiratory distress
Fatigue (more common in older adolescents)
GI symptoms
Nausea and vomiting
Diarrhea
Abdominal pain
Jaundice
Neurologic symptoms
Anxiety (more common in older adolescents)
Altered behavior
Seizures, coma
Thyroid storm is basically a life threatening acute exacerbation of the clinical features of thyrotoxicosis.
Thyroid storm also known as thyroid crisis is an acute, life threatening hypermetabolic state induced by excessive activity of thyroid hormones in individuals with thyrotoxicosis.
Exact pathogenesis not understood.
No clear cut clinical feature separation from thyrotoxicosis.
precipitants of thyroid storm include the following
Infection, especially pneumonia
Cerebrovascular accident
Acute coronary syndrome, Congestive heart failure
Pulmonary embolus
Diabetic ketoacidosis
Parturition / toxemia
Major trauma
Surgery
Iodine 131 Rx or iodine contrast agents
Rapid withdrawl of antithyroid medications
Although the exact pathogenesis of thyroid storm is not fully understood, the following theories have been proposed:
Patients with thyroid storm reportedly have relatively higher levels of free THs than patients with uncomplicated thyrotoxicosis, although total TH levels may not be increased.
Adrenergic receptor activation is another hypothesis. Sympathetic nerves innervate the thyroid gland, and catecholamines stimulate TH synthesis. In turn, increased THs increase the density of beta-adrenergic receptors, thereby enhancing the effect of catecholamines.
The dramatic response of thyroid storm to beta-blockers and the precipitation of thyroid storm after accidental ingestion of adrenergic drugs such as pseudoephedrine support this theory. This theory also explains normal or low plasma levels and urinary excretion rates of catecholamines.
However, it does not explain why beta-blockers fail to decrease TH levels in thyrotoxicosis.
Another theory suggests a rapid rise of hormone levels as the pathogenic source. A drop in binding protein levels, which may occur postoperatively, might cause a sudden rise in free hormone levels. In addition, hormone levels may rise rapidly when the gland is manipulated during surgery, during vigorous palpation during examination, or from damaged follicles following RAI therapy.
Other proposed theories include alterations in tissue tolerance to THs, the presence of a unique catecholaminelike substance in thyrotoxicosis, and a direct sympathomimetic effect of TH as a result of its structural similarity to catecholamines.
General symptoms
Fever
Profuse sweating
Poor feeding and weight loss
Respiratory distress
Fatigue (more common in older adolescents)
GI symptoms
Nausea and vomiting
Diarrhea
Abdominal pain
Jaundice
Neurologic symptoms
Anxiety (more common in older adolescents)
Altered behavior
Seizures, coma
Thyroid Storm and post-surgical hypoparathyroidismJin-Yi Hsu
Thyroid storm is a life-threatening condition, and early detection and early management are the most important. This is a case presentation about Grave's disease s/p subtotal thyroidectomy. However, the Grave's disease recurred and some precipitating factor induced the thyroid storm. Besides, post-surgical hypoparathyroid was found incidentally due to the seizure episode.
Perioperative Management of Hypothyroid Patients Undergoing Nonthyroidal SurgeryTerry Shaneyfelt
In these annotated PowerPoint slides I describe the perioperative evaluation and management of patients with hypothyroidism needing nonthyroid surgery. Remember to download these slides to view the annotations for each slide.
Thyroid storm is a life-threatening syndrome that results from an acute exacerbation of thyrotoxicosis. Prevention, prompt recognition, and appropriate intervention as discussed herein are key to the prevention of death and morbidity in affected patients. I hope you find it educating as well as enlightening.
This is a lecture by Dr. Pamela Fry from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
Perioperative Management of Hypertensionmagdy elmasry
Hypertension is most common medical reason for postponing surgery.How important is peri-operative hypertension?Hypertensive comorbidities associated with adverse perioperative outcomes .New Guidelines for managing patients with high blood pressure before surgery
Consequences of anesthesia on blood pressure regulation.
Thyroid Storm and post-surgical hypoparathyroidismJin-Yi Hsu
Thyroid storm is a life-threatening condition, and early detection and early management are the most important. This is a case presentation about Grave's disease s/p subtotal thyroidectomy. However, the Grave's disease recurred and some precipitating factor induced the thyroid storm. Besides, post-surgical hypoparathyroid was found incidentally due to the seizure episode.
Perioperative Management of Hypothyroid Patients Undergoing Nonthyroidal SurgeryTerry Shaneyfelt
In these annotated PowerPoint slides I describe the perioperative evaluation and management of patients with hypothyroidism needing nonthyroid surgery. Remember to download these slides to view the annotations for each slide.
Thyroid storm is a life-threatening syndrome that results from an acute exacerbation of thyrotoxicosis. Prevention, prompt recognition, and appropriate intervention as discussed herein are key to the prevention of death and morbidity in affected patients. I hope you find it educating as well as enlightening.
This is a lecture by Dr. Pamela Fry from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
Perioperative Management of Hypertensionmagdy elmasry
Hypertension is most common medical reason for postponing surgery.How important is peri-operative hypertension?Hypertensive comorbidities associated with adverse perioperative outcomes .New Guidelines for managing patients with high blood pressure before surgery
Consequences of anesthesia on blood pressure regulation.
Q: A 70 y.o. man is brought to ER by his nephew because he was found poorly responsive at home. The nephew had not checked on the patient for two weeks. The patient lives alone and has been noted by his nephew to be more confused and less active over the past few months.
The nephew was uncertain about the patient's past medical history. He recalls that the patient takes several pills per day for some 'heart issues,' blood pressure, and headaches.
He also recalls that the patient was seen in ER recently for muscle pains and was given opioid analgesics.
It Gives Information about Thyroid disease(its type), Thyroid Gland & Thyroid System. The Presentation also Give information on Hyperthyroidism ( like its Etiology, Symptoms, Diagnostic Evaluation and Treatment.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Anti ulcer drugs and their Advance pharmacology ||
Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
||Scope: Overview of various classes of anti-ulcer drugs, their mechanisms of action, indications, side effects, and clinical considerations.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
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These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
2. Physiology
Dietary iodine is absorbed by GI, converted to iodide ion and
actively transported into the thyroid gland. The end result is two
hormones-triiodothyroxine T3 and thyroxine T4. Although the gland
releases more T4 than T3, the latter is more potent and less protein
bound.
Most T3 is formed peripherally from partial deiodination of T4.
3. Thyroid hormone T3 increases carbohydrate and fat
metabolism and is an important factor in determining
growth and metabolic rate. An increase in metabolic rate is
accompanied by an increase in O2 consumption and CO2
production,,increasing minute ventilation. Heart rate and
contractility are also increased,,from an alateration in
adrenergic-receptor physiology , not from increase in
catecholamine concentrations.
4. Hyperthyroidism
Clinical syndrome which results from exposure of the body
tissues to excess circulating levels of free thyroid
hormones. More commons in female.
Causes of Hyperthyroidism :
1. Graves’ disease
2. Toxic multinodular goitre
3. TSH secreting pituitary tumors
4. Toxic thyroid adenoma
5. Over dosage of thyroid replacement hormone
6. * Neuromuscular :
• Muscle weakness
• Hyperactive reflexes
• Nervousness
• Fine tremor
• Periodic paralysis
* Diagnosis:
The diagnosis of hyperthyroidism is confirmed by abnormal TFT,
which may include an elevation in serum T4 and serum T3 and a
reduced TSH level.
8. Anesthetic Consideration
A) Preoparative:
Manifest hyperthyroidism increases the risk of perioperative complications
and is a contraindication for elective surgery, with the exception of
thyroidectomy as measure of last resort when conservative treatment has
failed to control the condition.
HISTORY AND EXAMINATION Thyroid hormone status should be evaluated in patients
with goitre. Goitre alone is most often associated with iodine-deficiency hypothyroidism,
but may also be present in patients with hyperthyroidism. The patient must be examined for
signs and symptoms of increased thyroid function. The neck should be inspected and the
presence of stridor on forced inspiration noted. Engorged jugular veins can indicate
retrosternal goitre.
9. INVESTIGATIONS Patients with suspected hyperthyroidism require determination of
T4, FT4, T3 and TSH in addition to routine laboratory data. Elevated hormone levels
may exist without clinical signs of hyperthyroidism. Chest and neck X-rays will show
the position of the trachea and reveal any compression or deviation caused by
goiter. Retrosternal goiter usually does not interfere with intubation even when the
trachea is displaced. Indirect laryngoscopy is performed preoperatively by many
surgeons to document vocal cord function. CT scan and MR scans can reveal the
magnitude and extent of tracheal stenosis.
10. All elective surgical procedures, including subtotal
thyroidectomy, should be postponed until the patient is
euthyroid with medical treatment. The patient should
have normal T3 and T4 and should not have resting
tachycardia. Antithyroid medications and beta adrenergic
antagonist are continued through the morning of surgery.
11. B) Intraoperative:
* Premedication and anxiety.
*Cardiovascular function and body temperature should be closely
monitored In patient with a history of hyperthyroidism.
*Drugs that stimulate sympathetic nervous system should be
avoided because of the possibility of increasing blood pressure and
heart rate. Ex. Ketamine, Pancuronium, Atropine, Ephedrine.
*Thiopental may be induction agent of choice as it possess
antithyroid activity at high doses.
12. *Adequate anaesthetic depth should be obtained prior to
laryngoscopy or surgical stimulation to avoid tachycardia,
hypertension, ventricular dysrhythmias.
*Anticipate exaggerated hypotensive response during induction as
patient may be hypovolemic .
*Eye protection .
*Muscle relaxants can be given safely.
*Patients with autoimmune thyrotoxicosis are associated with an
increase risk of myopathies and myasthenia gravis.
* Reversal with glycopyrrolate instead of atropine .
14. Thyroid Storm:
*Thyroid storm is most serious problem .
*Characterized by: hyperpyrexia, tachycardia, altered consciousness,
and hypertension .
*Precipitating factors: infection, trauma, surgery.
*Onset is usually 6-24 hours after surgery, but can happen
intraoperatively mimicking malignant hyperthermia .
15. Treatment:
ABC guideline
* Patient will be managed in Surgical ICU
* IV Hydration, cooling of patient
* IV Propranolol(0.5mg increments) /esmolol to control heart rate
until less than 100.
* Propylthiouracil 250mg 6 hourly orally or by NG tube .
* Sodium Iodide 1 gram over 12 hours correction of any precipitating
events (infection) .
* Cortisol is recommended if there is any coexisting adrenal gland
suppression .
* Mortality rate is approximately 20% .
16. *Recurrent laryngeal nerve palsy:
Unilateral – hoarseness Bilateral – stridor
*Hematoma formation : May cause airway compromise -
required immediate opening of neck wound .
*Hypoparathyroidism : May result from unintentional removal of
parathyroid glands. Hypocalcemia will result within 24-72 hours.
17. Hypothyroidism
Impaired secretion of thyroid hormones or under
activity of the thyroid glands leading to
hypometabolic state-
- A high TSH level
- A low Free T4 & T3 level in serum
- A low total T4 & T3 level
18. Causes of Hypothyroidism
1. Primary hypothyroidism
2. Autoimmune (Hashimoto’s thyroiditis)
3. Post thyroidectomy
4. Post radioactive iodine
5. Over dosage of antithyroid medication
6. Iodine deficiency
7. Secondary hypothyroidism (failure of the hypothalamic-
pituitary axis)
23. Medical Treatment
1. Replacement therapy with thyroxine - Start with a dose
of thyroxine 50 micgm / day for 3 weeks followed by -
100micgm / day for 3 weeks - Finally 150 micgm / day
single daily dose.
2. Follow-up : Clinical checkup, serum TSH & T4 level
24. Although elective surgery is best postponed until a euthyroid state is achieved,
patients requiring urgent or emergent surgery may proceed with surgery if they
have mild or moderate hypothyroidism
25. Anaesthetic consideration
# Euthyroid state is ideal.
# Continue thyroid replacement medication on morning of surgery.
# Aspiration prophylaxis – due to delayed gastric emptying times.
# Sedative & narcotic administered more cautiously - more prone to drug
induced respiratory depression.
27. Intraoperative
# Patients are more sensitive to hypotensive effects of
anesthetic agents because:
1. Decreased cardiac output
2. Blunted baroreceptor reflexes &
3. Decreased intravascular volume
28. # Ketamine or Etomidate may be induction agents of
choice
# Succinylcholine and non-depolarizing muscle relaxants
are generally safe for use.
# Used peripheral nerve stimulator for monitoring muscle
relaxant.
29. # Controlled ventilation is recommended as patients tend
to hypoventilate
# Hypothermia occurs quickly
# Hematological (anaemia, platelet, coagulation
dysfunction) disorder
30. # Electrolyte imbalances
# Hypoglycemia is common
# Extubation/Emergence may be delayed secondary to hypothermia,
respiratory depression, or slowed drug metabolism
31. Postoperative
# Try to maintain normothermia
# Cautiously administer Opioids ,Consider regional techniques or
Ketorolac for pain control
32. Emergency
Myxedema Coma
# Rare form of decompensated Hypothyroidism
# Medical emergency with mortality rate of
15- 20%
# Infection
# CNS depression - especially in elderly
33. Characterized by
- Stupor or coma
- Hypoventilation
- Hypothermia
- Bradycardia
- Hypotension,
- Severe dilutional hyponatremia (SIADH)
- CHF
34. Treatment
# IV thyroxine is indicated (L-thyroxine loading dose 300-500ug,
followed by 50ug/day for 24-48hrs).
# IV hydration with dextrose containing crystalloid .
# Correction of electrolyte abnormalities.
# Support cardiovascular and pulmonary systems as necessary .
# Stress dose steriod.
# Avoid sudden warming.