Thyroid Storm Botaro
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Transcript of Thyroid Storm Botaro
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IINTERESTINGNTERESTING CASECASE
CONFERENCECONFERENCE
Sanphetchuda Saetang
Resident 1 medicine CU
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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.
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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
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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%.
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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
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> 45: highly suggesitve ; 25-44: impending storm;
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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)
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ELECTROCARDIOGRAM
Sinus tachycardia (40 %)
Atrial fibrillation (10-20 %)
y > 60 y/o,
y Underlying structural heart disease
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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
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THYROID STORM
Treatment
y Initial stabilization includes airway protection,
oxygenation, fluids and cardiac monitoring
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THIONAMIDE
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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)
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IODINE THERAPY
Wolff-Chaikoff effect
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BETA-BLOCKADE
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GLUCOCORTICOIDS
Dexamethasone and hydrocortisone
Inhibit conversion ofT4 to T3
In severe thyrotoxicosis with hypotension 100 mg Q8H
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ALTERNATIVE THERAPIES
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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
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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.
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