Approach to evaluating and treating Chronic Heart Failure and Acute Heart Failure
Reference: Harrison’s Principles of internal medicine Harrison's 21st Ed (2022)
Severe hypertension that is a potentially life-threatening condition refers to a hypertensive crisis.
Severe hypertension is further classified into hypertensive emergencies or hypertensive urgencies.
Hypertensive emergency refers to a severe hypertension that is associated with new or progressive end-organ damage. In these clinical situations, blood pressure should be reduced immediately to prevent or minimize organ dysfunction.
Hypertensive urgency refers to severe hypertension without evidence of new or worsening end-organ injury.
A hypertensive emergency is hypertension with acute impairment of one or more
organ systems that can result in irreversible organ damage. Especially:-
Central nervous system
Cardiovascular system
Renal system.
The term hypertensive emergency is primarily used as a specific term for a hypertensive crisis with a diastolic blood pressure greater than or equal to 120mmHg and/or systolic blood pressure greater than or equal to 180mmHg.
Hypertensive emergency differs from hypertensive crisis in that, in the former, there is evidence of acute organ damage.
Hyperthyroidism is a very common name, when it comes to lifestyle diseases. Often a deeper and holistic approach towards your health will help you find long term solution, and hence you will be able to recognize your symptoms of Hyperthyroidism. Your thyroid gland, when starts secreting more amount of hormone, the condition is referred as hyperthyroidism. Thereby speeding up the bodily functions, including metabolism.
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.
Myxoedema coma Pharmacotherapeutic viewPranatiChavan
Myxedema coma is an extreme complication of hypothyroidism in which patients exhibit multiple organ abnormalities and progressive mental deterioration. The term myxedema is often used interchangeably with hypothyroidism and myxedema coma. Myxedema also refers to the swelling of the skin and soft tissue that occurs in patients who are hypothyroid. Myxedema coma occurs when the body's compensatory responses to hypothyroidism are overwhelmed by a precipitating factor such as infection.
sudden spike in blood pressure to 180/120 or higher
abt how we deal with it
what we need to do immediate action
maintain ASAP blood pressure in order to save the patients
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.
Approach to evaluating and treating Chronic Heart Failure and Acute Heart Failure
Reference: Harrison’s Principles of internal medicine Harrison's 21st Ed (2022)
Severe hypertension that is a potentially life-threatening condition refers to a hypertensive crisis.
Severe hypertension is further classified into hypertensive emergencies or hypertensive urgencies.
Hypertensive emergency refers to a severe hypertension that is associated with new or progressive end-organ damage. In these clinical situations, blood pressure should be reduced immediately to prevent or minimize organ dysfunction.
Hypertensive urgency refers to severe hypertension without evidence of new or worsening end-organ injury.
A hypertensive emergency is hypertension with acute impairment of one or more
organ systems that can result in irreversible organ damage. Especially:-
Central nervous system
Cardiovascular system
Renal system.
The term hypertensive emergency is primarily used as a specific term for a hypertensive crisis with a diastolic blood pressure greater than or equal to 120mmHg and/or systolic blood pressure greater than or equal to 180mmHg.
Hypertensive emergency differs from hypertensive crisis in that, in the former, there is evidence of acute organ damage.
Hyperthyroidism is a very common name, when it comes to lifestyle diseases. Often a deeper and holistic approach towards your health will help you find long term solution, and hence you will be able to recognize your symptoms of Hyperthyroidism. Your thyroid gland, when starts secreting more amount of hormone, the condition is referred as hyperthyroidism. Thereby speeding up the bodily functions, including metabolism.
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.
Myxoedema coma Pharmacotherapeutic viewPranatiChavan
Myxedema coma is an extreme complication of hypothyroidism in which patients exhibit multiple organ abnormalities and progressive mental deterioration. The term myxedema is often used interchangeably with hypothyroidism and myxedema coma. Myxedema also refers to the swelling of the skin and soft tissue that occurs in patients who are hypothyroid. Myxedema coma occurs when the body's compensatory responses to hypothyroidism are overwhelmed by a precipitating factor such as infection.
sudden spike in blood pressure to 180/120 or higher
abt how we deal with it
what we need to do immediate action
maintain ASAP blood pressure in order to save the patients
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.
hyperthyroidism, thyrotoxicosis, grave disease, thyroid storm, pregnancy, high risk pregnancy, pregnancy complications, management of thyrotoxicosis and thyroid storm in pregnancy
2012 Clinical Practice guidelines for hypothyroidism in adults: American Asso...Jibran Mohsin
This is presentation format of 2012 Clinical Practice guidelines for hypothyroidism in adults: American Association of Clinical Endocrinologists (AACE) / American Thyroid Association (ATA)
Introduction:
@ Thyroid releases T3 & T4
@ The ratio of T4 to T3 is 5:1, so most of the hormone released is
thyroxine
@ Most of the T3 in the blood is derived from thyroxine
@ T3 is three to four times more potent than T4
@ The affinity of the receptor site for T3 is about ten times higher than that for T4
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
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.
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
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.
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
Title: Sense of Smell
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 primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
263778731218 Abortion Clinic /Pills In Harare ,ABORTION WOMEN’S CLINIC +27730423979 IN women clinic we believe that every woman should be able to make choices in her pregnancy. Our job is to provide compassionate care, safety,affordable and confidential services. That’s why we have won the trust from all generations of women all over the world. we use non surgical method(Abortion pills) to terminate…Dr.LISA +27730423979women Clinic is committed to providing the highest quality of obstetrical and gynecological care to women of all ages. Our dedicated staff aim to treat each patient and her health concerns with compassion and respect.Our dedicated group ABORTION WOMEN’S CLINIC +27730423979 IN women clinic we believe that every woman should be able to make choices in her pregnancy. Our job is to provide compassionate care, safety,affordable and confidential services. That’s why we have won the trust from all generations of women all over the world. we use non surgical method(Abortion pills) to terminate…Dr.LISA +27730423979women Clinic is committed to providing the highest quality of obstetrical and gynecological care to women of all ages. Our dedicated staff aim to treat each patient and her health concerns with compassion and respect.Our dedicated group of receptionists, nurses, and physicians have worked together as a teamof receptionists, nurses, and physicians have worked together as a team wwww.lisywomensclinic.co.za/
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
2. Introduction
• Also known as thyrotoxic crisis, is an acute, life-threatening
complication of hyperthyroidism.
• An exaggerated presentation of thyrotoxicosis.
• sudden multisystem involvement.
• Mortality ≈ 10-75 %
• Diagnosis- clinical
• Can occur in any diagnosed/ undiagnosed case of – Graves’ disease,
TMNG, Toxic Adenoma, Iatrogenic thyrotoxicosis or any other cause
of hyperthyroidism and thyrotoxicosis
3. Epidemiology
• Rare
• It accounts for about 1% to 2% of admissions for hyperthyroidism.
US data-
• Incidence of storm is 0.57 to 0.76 cases per 100,000 per year in the normal population
• 4.8 to 5.6 cases per 100,000 per year in hospitalized patients
Japanese data-
• 0.2 per 100,000 population per year
• 0.22% of all thyrotoxicosis patients and 5.4% of hospitalized thyrotoxicosis
• M:F-1:3 same as in non thyrotoxic storm
• Average age- 43-45 years
4. Pathophysiology
• Rapid increase in thyroid hormone levels rather than the absolute hormone level –
1. Thyroid surgery
2. Following radioactive iodine t/t
3. After sudden discontinuation of the antithyroid drug
4. After administration of the large dose of iodine in contrast studies.
• Hyperactive sympathetic nervous system- acute stress or infections, causing cytokines release
and altered immunological disturbances
• The degree of thyroid hormone level is not directly related to a higher incidence of thyroid storm
5. Events Associated with the Onset of Thyrotoxic
Storm
Infection
Other acute medical illness
Acute emotional stress
Acute psychosis
Non thyroid surgery
Parturition
Trauma
Discontinuation of anti thyroid drug therapy
After radioiodine therapy
Post-thyroidectomy
After high-dose iodine administration
Iodinated radiographic contrast agents
RARE ASSOCIATIONS-
Vigorous palpation of thyroid gland
Subacute thyroiditis
Thyroxine over dosage (thyrotoxicosis factitia) Aspirin
intoxication
Hydatidiform mole
Organophosphate intoxication
Neurotoxins
Cytotoxic chemotherapy
6.
7. History and Physical examination
H/O- fever, CVS (tachycardia, heart failure, arrhythmia
central nervous system (CNS) manifestations and GI symptoms (nausea,
vomiting, diarrhea, abdominal pain, intestinal obstruction, and acute hepatic
failure)
JTA , CNS involvement – POOR prognosis, increased mortality
Physical examination-high temperature, tachycardia, orbitopathy, goiter,
hand tremors, moist and warm skin, hyperreflexia, systolic hypertension, and
jaundice.
Investigations- TFT, CBC, LFT, RFT, Cortisol, Blood Glucose, Calcium levels
Imaging- Chest X ray, MRI Brain, ECG
*It is not necessary to have a very high level of thyroid hormone to cause
thyroid storm.
8.
9. Burch Wartofsky Point Scale (BWPS)
THERMOREGULATORY
DYSFUNCTION
SCORE CARDIOVASCULAR DYSFUNCTION SCORE
99-99.9 F (37.2-37.7 C) 5 TACHYCARDIA
100-100.9 F (37.8-38.2 C) 10 99-109 BPM 5
101-101.9 F (38.3-38.8 C) 15 110-119 BPM 10
102-102.9 F (38.9-39.3 C) 20 120-129 BPM 15
103-103.9 F (39.4-39.9 C) 25 130-139 BPM 20
≥ 104 F (>40.0 C) 30 ≥ 140 BPM 25
CENTRAL NERVOUS SYSTEM SCORE CONGESTIVE HEART FAILURE SCORE
Agitation 10 Pedal Edema ( Mild) 5
Delirium/Psychosis/Lethargy 20 Bibasal Rales (Moderate) 10
Seizure/Coma 30 Pulmonary Edema (Severe) 15
GI-HEPATIC DYSFUNCTION SCORE Atrial fibrillation Present 10
Diarrhea,Nausea/Vomiting,Abdo
minal Pain
10 Precipitant History Present 10
Severe jaundice 20
10. INTERPRETATION-
• Thyroid storm highly likely >60
• Likely, 45–60
• Impending, 25–44
• unlikely, <25
• When it is not possible to distinguish a finding due to an intercurrent
illness from that of thyrotoxicosis, the higher point score is given so
as to favor empiric therapy
Reference-Burch HB, Wartofsky L. Life-threatening thyrotoxicosis:
thyroid storm. Endocrinol Metab Clin North Am 1993;22:263–277
11. The Japanese Thyroid Association (JTA)
Prerequisite for diagnosis
Presence of thyrotoxicosis with elevated levels of free triiodothyronine (FT3) or free thyroxine (FT4)
Symptoms
1. Central nervous system (CNS) manifestations: Restlessness, delirium, mental aberration/psychosis,
somnolence/lethargy, coma ( ≥1 on the Japan Coma Scale or ≤14 on the Glasgow Coma Scale)
2. Fever : ≥ 38˚C
3. Tachycardia : ≥ 130 beats per minute or heart rate ≥ 130 in atrial fibrillation
4. Congestive heart failure (CHF) : Pulmonary edema, moist rales over more than half of the lung field,
cardiogenic shock, or Class IV by the New York Heart Assciation or ≥ Class III in the Killip classification
5. Gastrointestinal (GI)/hepatic manifestations : nausea , vomiting, diarrhea, or a total bilirubin level ≥ 3.0
mg/dL
12. Diagnosis
Grade of TS Combinations of
features
Requirements for diagnosis
TS 1 First combination Thyrotoxicosis and at least one CNS manifestation
and fever, tachycardia, CHF, or GI/ hepatic
manifestations
TS 1 Alternate combination Thyrotoxicosis and at least three combinations of
fever, tachycardia, CHF, or GI/ hepatic
manifestations
TS 2 First combination Thyrotoxicosis and a combination of two of the
following: fever, tachycardia, CHF, or GI/hepatic
manifestations
TS 2 Alternate combination Patients who met the diagnosis of TS1 except that
serum FT3 or FT4 level are not available
TS1, “Definite” TS; TS2, “Suspected” TS.
13. Exclusion and provisions in JTA
Cases are excluded if other underlying diseases clearly causing any of
the following symptoms:
1.Fever (e.g., pneumonia and malignant hyperthermia
2.Impaired consciousness (e.g., psychiatric disorders and cerebrovascular disease)
3.Heart failure (e.g.acute myocardial infarction), and liver disorders (e.g., viral hepatitis and acute
liver failure).
• Difficult to determine whether the symptom is caused by TS or is
simply a manifestation of an undelying disease;
• Symptom should be regarded as being due to a TS that is caused by
these precipitating factors.
• Clinical judgment in this matter is required.
14. Comparing BWPS and JTA
1. BWPS of ≥ 45 or JTA Category TS 1 and TS 2 with e/o systemic decompensation require aggressive therapy
2. BWPS of 25-44, decision of aggressive therapy should be based on clinical judgment
3. JTA, TS 1 & TS 2 has tendency of underdiagnosis compared to BWPS ≥ 45
4. Similar rates of overdiagnosis with two systems
5. A BWPS of ≥ 45 is more sensitive than a JTA classification of TS1 or TS2 patients with a clinical diagnosis of
thyroid storm.
But for BWPS 25-44 use clinical judgement.
15. Management
1. Therapy to control increased adrenergic tone: Beta-blocker
2. Therapy to reduce thyroid hormone synthesis: Thionamide
3. Therapy to reduce the release of thyroid hormone: Iodine solution
4. Therapy to block peripheral conversion of T4 to T3: Iodinated
radiocontrast agent, glucocorticoid, PTU, propranolol
5. Therapy to reduce enterohepatic recycling of thyroid hormone: Bile
acid sequestrant
17. • T4 is acted by the thyroidal type 1 and 2 deiodinases (D1 and D2) ,
this conversion is inhibited by PTU, that inhibits D1
• At synthesis level- ratio of T4 to T3 in human Tg is 15:1
• At secretion level- ratio of T4 to T3 in thyroid secretion is
approximately 10:1 ( catalyzed by D1 and D2)
• It is enhanced in Graves’ Disease, marked increase of the ratio of T3
to T4 production
• An inhibition of the D1-catalyzed T4 to T3 conversion may contribute
to the rapid effect of PTU to reduce circulating T3 in patients with
Graves disease
18. • Iodide inhibits the stimulation of thyroid adenylate cyclase by TSH
and by the stimulatory immunoglobulins of Graves disease.
• Increasing iodination of Tg also increases its resistance to hydrolysis
by acid proteases in the lysosomes
19. Thyrotoxic storm – Drugs and doses
DRUGS DOSING COMMENTS
Propyl thiouracil ( can be given IV) 500-1000 mg load then 250 mg
every 4 hourly
Blocks new hormone synthesis ( -
D1)
Methimazole 60-80 mg/day Blocks T4 to T3 conversion, (-) new
hormone synthesis
Propanolol 60-80 mg every 4 hours Consider invasive monitoring in congestive
heart failure patients, blocks T4 to T3
conversion in high doses
Alternate drug: esmolol infusion
Iodine ( saturated solution of
Potassium Iodide)
5 drops ( 0.25 ml or 250 mg) orally
every 6 hours
Do not start until 1 hr after ATD,
blocks new hormone synthesis and
release, alternate: Lugol’s iodine
Hydrocortisone 300 mg IV load then 100 mg every
8 hrs
May block T4 to T3 conversion,
prophylaxis against relative Adrenal
insufficiency, alternate-
dexamethasone
21. Management of Thyrotoxic storm
1.Reduction of thyroid hormone production and
secretion
Inhibition of T4 and T3 synthesis
• Propylthiouracil, methimazole Inhibition of T4 and T3
secretion
• Inorganic iodide (potassium iodide, Lugol solution)
• Radiographic contrast agents (sodium ipodate, iopanoic
acid)
• Lithium carbonate
• Thyroidectomy
2.Therapy directed against systemic disturbances
• Treatment of fever
• Acetaminophen
• External cooling
Correction of volume depletion and poor nutrition
• Intravenous fluid and electrolytes Glucose (calories)
Vitamins
• Supportive therapy Oxygen
• Vasopressor drugs
Treatment for congestive heart failure (diuretics, digoxin)
3.Amelioration of the peripheral actions of thyroid
hormone and Removal of T4 and T3 from serum-
• Inhibition of extra thyroidal conversion of T4 to T3 -PTU
• Radiographic contrast agents (sodium ipodate, iopanoic
acid)
• Glucocorticoids
• Propranolol or other β-adrenergic antagonist drugs
• Cholestyramine
• Plasmapheresis, hemodialysis, hemoperfusion
4.Treatment of any precipitating or underlying illness
22. Preparation of rectal formulations of
thionamides
Methimazole Propylthiouracil
Suppository-Dissolve 1200 mg methimazole in 12 mL
of water, and add to 52 mL cocoa butter containing 2
drops of polysorbate (Span) 80. Stir mixture to form
an emulsion, and pour into 2.6 mL suppository molds
to cool.
* Avoid phosphate-containing rectal preparations in
patients with kidney insufficiency or heart failure
Suppository-Dissolve 200 mg of propylthiouracil in a
polyethylene glycol base, and put into suppository
tablets
Retention enema-Dissolve 8 to 12 (50 mg) tablets of
propylthiouracil in 90 mL of sterile water.
OR
Dissolve 8 (50 mg) tablets of propylthiouracil in 60 mL
of mineral oil enema (eg, Fleet mineral oil) or in 60 mL
of sodium phosphates enema solution* (eg, Fleet
enema phospho-soda).
For either enema preparation: Administer by Foley
catheter inserted into the rectum, with balloon
inflated to prevent leakage for 2-hour retention.
1.Nabil N, Miner DJ, Amatruda JM. Methimazole: an alternative route of administration. J Clin Endocrinol Metab 1982; 54:180.
2.Walter RM Jr, Bartle WR. Rectal administration of propylthiouracil in the treatment of Graves' disease. Am J Med 1990; 88:69
23.
24. Myxedema Coma
• Myxedema coma is a rare life-threatening clinical condition in
patients with longstanding severe untreated hypothyroidism, in
whom adaptive mechanisms fail to maintain homeostasis.
• First reported in 1879 by Ord from the St. Thomas Hospital, London.
• ≈ 200 cases have been reported subsequently
• Prognosis poor with a reported mortality between 20% and 50%.
25.
26.
27. Diagnosis and d/d
Three key features-
• Altered mental status
• Defective thermoregulation: hypothermia
• Precipitating event
28. Examination and Investigations
Physical Examination
• Hypothermia
• Hypoventilation
• Hypotension
• Bradycardia
• Dry coarse skin
• Macroglossia
• Delayed DTR
• Absence of mild diastolic hypertension in severely
hypothyroid patients is a warning sign of
impending myxedema coma.
Investigations
• Anemia
• Hyponatremia
• Hypoglycaemia
• Hypercholesterolemia
• High serum creatine kinase
• Low serum FT4 and high serum TSH (Serum TSH
can be low or normal)
31. • ≥ 60 highly S/O or diagnostic of myxedema coma
• 25 to 59 S/O of risk for myxedema coma
• < 25 is unlikely to indicate myxedema coma
• ECG Changes- QT prolongation, low-voltage complexes, bundle branch
blocks, nonspecific ST- T changes or heart blocks.
Reference-Popoveniuc G, Chandra T, Sud A, et al. A diagnostic scoring
system for myxedema coma. Endocr Pract 2014;20:808–817
32. Management- Hypothyroidism
1.L4 alone-
A. Initial dose 300–500 mcg IV
B. Then 50–75mcgdaily IV or p.o. if conscious
C. Once stable, continue at 1.6mcg/kg while monitoring FT4 and TSH
2.L3 alone
A. Initial dose 30–50mcg IV
B. Follow with 10mcg q6h for next 24–48hr
C. Once conscious and taking oral medications ,switch to levothyroxine 75–100mcg daily
D. Continue at 1.6mcg/kg while monitoring FT4 and TSH levels
3.CombinationT4 PlusT3
A. Initial L4 dose 4mcg/kg lean bodyweight IV (≈200–250mcg) together with 20 mcg T3 IV.
B. Continue with T3 ,10mcg q8–12h
C. If still comatose on day2 (and day3)administer L4 100mcg IV
D. Once conscious and taking oral medications ,discontinue T3and continue T4 at 1.6mcg/kg while monitoring
FT4 and TSH levels
33. 2.Hypocortisolemia -Hydrocortisone , IV , 50 to 100 mg every 6 to 8 hours for several days, tapered then
stopped
3. Hypoventilation – esp those with morbid obesity, sedatives
4. Hypothermia – passive warming, blankets, core body temperature, electrical thermometers
5. Hyponatremia – cautious use of 3 percent saline ( Na < 120 mmol/L)with or without furosemide, NS
6. Hypotension – judicious use of iv fluid , 5-10 % dextrose in NS, hydrocortisone
7. Hypoglycemia – IV glucose
8. Precipitating event - vigorous search , Signs of infection (like fever, tachycardia, leukocytosis) may be
absent, prophylactic antibiotics
34.
35.
36. Take Home Message
• Rare conditions with high mortality
• High clinical suspicious
• Try all available options