Thyroid Storm Botaro

8/6/2019 Thyroid Storm Botaro

1/19

IINTERESTINGNTERESTING CASECASE

CONFERENCECONFERENCE

Sanphetchuda Saetang

Resident 1 medicine CU


2/19

THYROID STORM

Accelerated Hyperthyroidism

extreme accentuation of thyrotoxicosis

It is an uncommon but serious complication,

Usually association with Graves' disease butsometimes with toxic multinodular goiter.

frequently followed thyroidectomy in

hyperthyroid patients

abrupt onset and occurs in pts in whompreexisting thyrotoxicosis has been treated

incompletely or has not been treated at all.


3/19

PRECIPITATING CAUSE

Withdrawal ofantithyroid drug

Infection/Sepsis

Surgery

Trauma

Iodinated contrast dyes

Hypoglycemia

Childbirth

Vigorous palpation ofthyroid

Burn injury

Diabetic ketoacidosis

Pulmonarythromboembolism

Cerebrovascularaccident

Seizure disorder

Radioactive iodine

therapy

Emotional stress


4/19

THYROID STORM

The mechanism related to cytokine release and

acute immunologic disturbance by precipitating

condition

serum thyroid hormone levels in crisis are notappreciably greater than those in severe

uncomplicated thyrotoxicosis

If left untreated the mortality rate is as high as

75 to 90%.


5/19

CLINICAL PICTURE

severe hypermetabolism.

y Fever

y Sweating

y Marked sinus tachycardia or ectopic origin

y Arrhythmias , pulmonary edema , CHF

y Tremulousness and restlessness

y delirium or frank psychosis

Nausea, vomiting, and abdominal pain may occurearly in the course.

y As the disorder progresses, apathy, stupor, and coma and

hypotensiony history of preexisting thyrotoxicosis or with goiter or

exophthalmos

emergency Rx should not await laboratoryconfirmation


6/19

> 45: highly suggesitve ; 25-44: impending storm;


7/19

LAB

o free T4 and free T3

qTSH

T3/ T4 ratioy > 20: Graves disease and toxic nodular goiter

y < 15: thyroiditis, iodine exposure

Hyperglycemia, hypercalcemia, elevated

alkaline phosphatase, leukocytosis, andelevated liver enzymes

Cortisol o (normal level adrenal insufficiency)


8/19

ELECTROCARDIOGRAM

Sinus tachycardia (40 %)

Atrial fibrillation (10-20 %)

y > 60 y/o,

y Underlying structural heart disease


9/19

AIMOF TREATMENT

Treatment can then be divided into 5 areas:

General supportive care

Inhibition of thyroid hormone synthesis

Retardation of thyroid hormone release

Blockade of peripheral thyroid hormone effects

Identification and treatment of precipitating events


10/19

THYROID STORM

Treatment

y Initial stabilization includes airway protection,

oxygenation, fluids and cardiac monitoring


11/19

THIONAMIDE


12/19

SIDE EFFECT

Common

y Abnormal sense of taste, pruritus, urticaria, fever,

and arthralgias

Severe and rarey Agranulocytosis (0.35%, within 3 months)

y Hepatotoxicity (0.1-0.2%)

y Vasculitis (more common in PTU)


13/19

IODINE THERAPY

Wolff-Chaikoff effect


14/19

BETA-BLOCKADE


15/19

GLUCOCORTICOIDS

Dexamethasone and hydrocortisone

Inhibit conversion ofT4 to T3

In severe thyrotoxicosis with hypotension 100 mg Q8H


16/19

ALTERNATIVE THERAPIES


17/19

TREATMENT

monitored in a medical intensive care unit during

the initial phases of therapy

Supportive measures include correction of

dehydration and hypernatremia, administration of glucose, Vitamin B

Hyperpyrexia should be treated vigorously. In

mild cases, acetaminophen ,cold blanket or ice

packs.

y Avoided ASA because compete with T3, T4 for binding

to TBG and transthyretin >>increase the free

hormone levels

Clinical stable >> total thyroidectomy, I-131


18/19

REFERENCE

Larsen. Special Aspects ofThyrotoxicosis.

In: Textbook of Endocrinology. 10th edition.

Elsevier, 2003: 412-414.

Mechem C.S

evere hyperthermia:H

eat strokes;Neuroleptic malignant syndrome; and malignant

hyperthermia.Up to Date Online. 2004.

Singhal A. Thyroid Storm. eMedicine. 2004.


19/19

Documents

Thyroid Storm Botaro