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Thyroid Storm
Tintinalli Chapter 215
12/15/05
Prepared by Trent W. Smith
Lecture by Dr. Klien MD
Hyperthyroidism
Occurs in in all ages
Uncommon under the age of 15
Hyperthyroidism
Toxic multinodular and toxic nodular
goiters are the next most common
etiologies
Usually occurs in older populations
Commonly with previous history of goiter
Often with milder symptoms of thyrotoxicosis
Hyperthyroidism
Amiodarone-induced thyrotoxicosis (AIT)
Amiodarone is iodine rich and may cause
both hyper and hypothyroidism
Difficult to treat because of incomplete
understanding of mechanism
Two major forms exists
Type 1 occurs with a normal thyroid
Type 2 occurs with a abnormal thyroid
Hyperthyroidism
Hyperthyroidism resembles a state of
increased adrenergic activity despite a
normal or low serum cortisol level
Classic complaints include heat
intolerance, palpitations, weight loss,
sweating, nervousness, and fatigue
Hyperthyroidism
Symptoms
Signs
Weaknes
Goiter/thyroid burit
Fatigue
Hyperkinesis
Heat intolerance
Opthalmopathy
Nervousness
Lid retraction/stare
Increased sweating
Lid lag
Tremors
Tremor
Palpitations
Weight loss
Hyperreflexia
Hyperdefication
Tachycardia/arrhythmia
Dyspnea
Systolic hypertension
Menstrual abnormalities
Hyperthyroidism
Confirmed by thyroid function test
Elevated free T4 and Low TSH
In some cases of graves disease T4 may be
normal and TSH decreased but the patient
appears thyrotoxic
T3 level should be done to rule out T3
toxicosis
Hypothyroidism secondary to pituitary
adenoma will have elevated TSH levels
Hyperthyroidism
Treatment
Palliative treatment of mild hyperthyroidism is
accomplished using B-blockers
Most commonly used is propanolol
Hyperthyroidism
Treatment cont.
Toxic multinodular goiter and solitary
adenomas may be treated with radioiodine
therapy
Thryoiditis is usually self limited and therapy is
rarely needed
Thyroid Storm
A life threatening hypremetabolic state due to
hyperthyroidism
Mortality rate is high (10-75%) despite treatment
Usually occurs as a result of previously
unrecognized or poorly treated hyperthyroidism
Thyroid hormone levels do not help to
differentiate between uncomplicated
hyperthyroidism and thyroid storm
Thyroid Storm
Preciptatnts of Thyroid Storm
(tabel 215-4)
Infection
Trauma
DKA
MI
CVA
PE
Surgery
Withdrawal of thyroid
med
Iodine administration
Palpation of thyroid
gland
Ingestion of thyroid
hormone
Thyroid Storm
Clinical features
The most common signs are fever,
tachycardia out of proportion to the fever,
altered mental status, and diaphoresis
Clues include a history of hyperthyroidism,
exophthalmoses, widened pulse pressure and
a palpable goiter
Patients may present with signs of CHF
Thyroid Storm
Clinical features cont.
Common GI symptoms include diarrhea and
hyperdefication
Apathetic thyrotoxicosis is a distinct
presentation seen in the elderly
Characteristic symptoms include lethargy, slowed
mentation, and apathetic facies
Goiter, weight loss , and proximal muscle
weakness also present
Thyroid Storm
Diagnosis
Thyroid storm is a clinical diagnosis based
upon suspicion and treated empirically
Lab work is non specific and may include
Leukocytosis, hyperglycemia, elevated
transaminase and elevated bilirubin
Thyroid Storm
Treatment
Initial stabilization includes airway protection,
oxygenation, fluids and cardiac monitoring
Treatment can then be divided into 5 areas:
Thyroid Storm
Other consideration:
Corticosteroids
Hydrocortisone 100 mg IV q 8 h or
dexamethosone 2 mg IV q 6 hr
Antipyretics
Cooling blanket
acteaminophen 650 mg PO q 4-6h
Thyroid Storm
Treatment cont
Propranolol has the additional effects or blocking
perpheral conversion of T4-T3
Avoid Salicylates because it may displace T4 from
TBG
If the patient continues to deteriorate despite
appropriate therapy circulating thyroid hormone may
be removed by plasma transfusion, plasmapheresis,
charchoal plasmaperfusion
Remember you must not administer iodine until
the synthetic pathway has been blocked
Thyroid Storm
Disposition
Admit to the ICU
Hypothyroidism and
Myxedeam Coma
Tintinalli Chapter 215
12/15/05
Prepared by Trent W. Smith
Lecture by Dr. Klien MD
Hypothyroidism
Occurs when there is insufficient hormone
production or secretion
Occurs more frequently in women (0.6 to 5.9 %)
The most common etiologies are
Primary thyroid failure due to autoimmune diseases
(Hashimoto thyroiditis is the most common)
Idiopathic causes
Ablative therapy
Iodine deficiency
May be transient
Pathophysiology is unclear but may be viral in nature
Hypothyroidism
Etiologies of Hypothyroidism
Primary
Autoimmune etiologies
Hashimotos is the most common
Idopathic
Post ablation (surgical, radioiodine)
Post external radiation
Thryoiditis (subacute, silent, postpartum)
Postpartum thyroiditis occurs within 3-6 months and occurs in
2- 16 % of women
Self limited etiologies, often prededed by hyperthroid phase
Hypothyroidism
Etiologies of Hypothyroidism
Post Partum
Occurs 3-6 months post partum and occurs in 2-16% of
women
Secondary (pituitary)
Neoplasm
Infiltrative Dz.
Hemorrhage
Tertiary (hypothalamic)
Neoplasm
Infiltrative Dz.
Hypothyroidism
Etiologies of Hypothyroidism
Drugs
Amiodarone
Occurs in 1-32% of patients
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
Lithium
Acts similarly to iodine and inhibit thyroid hormone release
Hypothyroidism
Clinical Features
The typical symptoms of hypothyroidism
include fatigue, weakness, cold intolerance,
constipation, weight gain, and deepening of
voice.
Cautaneous signs include dry, scaly, yellow
skin, non-pitting, waxy edema of the face and
extremities (myxedema): and thinning
eyebrows
Hypothyroidism
Clinical Features cont.
Cardiac findings include bradycardia,
enlarged heart, and low-voltage
electrocardiogram
Paresthesia, ataxia, and prolongation or
DTRs are characteristic neurologic findings
See table below for more complete list
Hypothyroidism
Symptoms and Signs or Hypothyroidism
Symptoms
Signs
Fatigue
Hoarseness
Weight Gain
Hypothermia
Cold intolerance
Periobital puffiness
Depression
Menstrual irregularities
Constipation
Joint Pain
Nonpitting edema
Muscle cramps
Bracycardia
Infertility
Peripheral Neuropathy
(table 216-2)
Hypothyroidism
Treatment
Most patient with uncomplicated symptomatic
Hypothyroidism may be referred to the
primary physician for further evaluation and
initiation of treatment
If hypothyroidism is due to a secondary
etiology initiation of thyroid hormone therapy
may exacerbate preexisting adrenal
insufficiency
Myxedema
Myxedema is a rare life threatening
decompensation of hypothyroidism
Usually in individuals with long-standing
hypothyroidism
Most often seen in the winter months
More common in elderly women with
underdiagnosed or undertreated
hypothyroidism
Myxedema
Precipitating events include
Infection
CHF
Trauma
CVA
Exposure to cold
Drugs
Sedatives
Lithium
Amiodarone
Myxedema
In addition to the clinical features of hypothyroidism
patients may present with
Hypothermia
Altered metal status
Coma, delusions, and psychosis (myxedema maddness)
Hyponatremia
Dilutional secondary to decreased free-water clearance
Hypoglycemia
Secondary to impaired gluconeogenesis
Hypotension
Bradycardia
Respiratory Failure
Secondary to decreased strength of respiratory muscle
Hypercapnia and hypoxia is common
Myxedema
Diagnosis
Must have high clinical suspicion
Commonly has Hx. Of hypothyroidism
Delcine in function is usually insidious in
onset
Myxedema
Diagnosis cont
Laboratory evaluation may reveal
Anemia
Hyponatremia
Hypoglycemia
Transaminases
CPK
LDH
Po2 and PCo2 on ABGs
Myxedema
Diagnosis cont.
EKG may reveal
Sinus Bradycardia
Prolonged QT interval
Low voltage
Flattened or inverted T waves
Myxedema
Treatment (see table 216-5 below)
No prospective studies on optimal therapy have been
done thus treatment recommendations are not
uniform
Airway stabilization with adequate oxygenation and
ventilation or vital
Cardiovascular status must be monitored closely
Hypothermic patients should be gradually rewarmed
with gentle passive external rewarming
Hypotension from reversal of hypothermic vasoconstriction
should be avoided
Myxedema
Treatment cont.
Hyponatremia typically responds to fluid
restrictions. Severe cases may require
hypertonic saline with lasixs
Vasopressors are usually ineffective and
should only be used in severe hypotension
Lovothyroxine 300-500 mcg slow IVP
followed by 50-100 mcg daily
Myxedema
Treatment cont.
L-triiodothyronine 25 mcg IV or orally q 8 h is a
alternative
This dose should be halved in patients with cardiovascular
disease
Myxedema
Recognition
Supportive therapy including ventilatory support
Thyroid replacement
Glucocorticoid
Hypoglycemia
Electrolyte correction
Hypothermia
Dextrose-containing IV fluids
Monitoring
Myxedema
Disposition
Admit to appropiately monitored bed
Questions
1. Hyperthyroidism is Characterized by
which of the following
A. Fatigue
B. Palpitations
C. Weight Loss
D. Heat intolerance
E. All the above
4. T or F Hyperthyroidism is more
common in women
5. T or F Hypothyroidism is more common
in women
6. T or F Mild hyperthyroidism may be
treated with B-blockers