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Thyroid storm

(thyroid crisis) is a potentially life-threatening condition for people who have hyperthyroidism. Thyroid storm happens when your thyroid gland suddenly releases large amounts of thyroid hormone in a short period of time. If you have thyroid storm, you will need emergency medical treatment. Thyroid storm is more likely to develop when a person has a serious health problem in addition to hyperthyroidism or in people who have untreated or undertreated Graves' disease. The problem usually happens after a stressful event or a serious illness, such as a major infection. It may also be triggered by surgery or by using iodine for a CT scan or in radioactive iodine therapy. Symptoms of thyroid storm include: Feeling extremely irritable or grumpy. High systolic blood pressure, low diastolic blood pressure, and fast heartbeat. Nausea, vomiting, or diarrhea. High fever. Shock and delirium. Feeling confused. Feeling sleepy. Yellow skin or eyes. Symptoms of heart failure, such as breathing problems or feeling very tired. Thyroid storm can lead to coma, heart failure, or death. Thyrotoxic crisis (or thyroid storm) is a rare but severe complication of hyperthyroidism, which may occur when a thyrotoxic patient becomes very sick or physically stressed. Its symptoms can include: an increase in body temperature to over 40 degrees Celsius (104 degrees Fahrenheit), tachycardia, arrhythmia, vomiting, diarrhea, dehydration, coma,[11] and death. Thyroid storm requires prompt treatment and hospitalization. The main treatment is to decrease the circulating thyroid hormone levels and decrease their formation. Propylthiouracil and methimazole are two agents that decrease thyroid hormone synthesis and are usually prescribed in fairly high doses.

To inhibit thyroid hormone release from the thyroid gland, sodium iodide, potassium iodide, and/or Lugol's solution can be given. Beta blockers such as propranolol (Inderal, Inderal LA, Innopran XL) can help to control the heart rate, and intravenous steroids may be used to help support the circulation. Hyperthyroidism:

Antithyroid drugs
Thyrostatics (antithyroid drugs) are drugs that inhibit the production of thyroid hormones, such as carbimazole (used in UK) and methimazole (used in US), and propylthiouracil. Propylthiouracil also works outside the thyroid gland, preventing conversion of (mostly inactive) T4 to the active form T3. Because thyroid tissue usually contains a substantial reserve of thyroid hormone, thyrostatics can take weeks to become effective, and the dose often needs to be carefully titrated over a period of months, with regular doctor visits and blood tests to monitor results.

Beta-blockers
Many of the common symptoms of hyperthyroidism such as palpitations, trembling, and anxiety are mediated by increases in beta adrenergic receptors on cell surfaces. Beta blockers, typically used to treat high blood pressure, are a class of drugs that offset this effect, reducing rapid pulse associated with the sensation of palpitations, and decreasing tremor and anxiety. Thus, a patient suffering from hyperthyroidism can often obtain immediate temporary relief until the hyperthyroidism can be characterized with the Radioiodine test noted above and more permanent treatment take place.

Iodine-131 (radioiodine) radioisotope therapy, which was first


pioneered by Dr. Saul Hertz,[26] radioactive iodine-131 is given orally (either by pill or liquid) on a one-time basis, to severely restrict, or altogether destroy the function of a hyperactive thyroid gland.

Food and diet


Patients cannot have foods high in iodine, such as edible seaweed and kelps.

Stroke:

patients with intracerebral bleeds are more likely to have headache, altered mental status, seizures, nausea and vomiting, and/or marked hypertension, none of these findings reliably distinguishes between hemorrhagic and ischemic stroke. The etiologies of stroke are varied, but they can be broadly categorized into ischemic or hemorrhagic. Approximately 80-87% of strokes are from ischemic infarction caused by thrombotic or embolic cerebrovascular occlusion. Intracerebral hemorrhages account for most of the remainder of strokes, with a smaller number resulting from aneurysmal subarachnoid hemorrhage. Risk factors The risk of hemorrhagic stroke is increased with the following factors: Advanced age Hypertension (up to 60% of cases) Previous history of stroke Alcohol abuse Use of illicit drugs (eg, cocaine, other sympathomimetic drugs) Causes of hemorrhagic stroke include the following[8, 9, 11, 12, 13] : Hypertension Cerebral amyloidosis Coagulopathies Anticoagulant therapy Thrombolytic therapy for acute myocardial infarction (MI) or acute ischemic stroke (can cause iatrogenic hemorrhagic transformation) Arteriovenous malformation (AVM), aneurysms, and other vascular malformations (venous and cavernous angiomas) Vasculitis Intracranial neoplasm Hypertension The most common etiology of primary hemorrhagic stroke (intracerebral hemorrhage) is hypertension. At least two thirds of patients with primary intraparenchymal hemorrhage are reported to have preexisting or newly diagnosed hypertension. Hypertensive small-vessel disease results from tiny lipohyalinotic aneurysms that subsequently rupture and result in intraparenchymal hemorrhage. Typical locations include the basal ganglia, thalami, cerebellum, and pons. Aneurysms and subarachnoid hemorrhage

The most common cause of atraumatic hemorrhage into the subarachnoid space is rupture of an intracranial aneurysm. Aneurysms are focal dilatations of arteries, with the most frequently encountered intracranial type being the berry (saccular) aneurysm.

History
Obtaining an adequate history includes determining the onset and progression of symptoms, as well as assessing for risk factors and possible causative events. Such risk factors include the following: Previous transient ischemic attack (TIA) and stroke Hypertension Diabetes Smoking Arrhythmia and valvular disease Illicit drug use Use of anticoagulants Risk factors for thrombosis A history of trauma, even if minor, may be important, as extracranial arterial dissections can result in ischemic stroke. Hemorrhagic versus ischemic stroke Symptoms alone are not specific enough to distinguish ischemic from hemorrhagic stroke. However, generalized symptoms, including nausea, vomiting, and headache, as well as an altered level of consciousness, may indicate increased intracranial pressure and are more common with hemorrhagic strokes and large ischemic strokes. Seizures are more common in hemorrhagic stroke than in the ischemic kind. Seizures occur in up to 28% of hemorrhagic strokes, generally at the onset of the intracerebral hemorrhage or within the first 24 hours. Focal neurologic deficits The neurologic deficits reflect the area of the brain typically involved, and stroke syndromes for specific vascular lesions have been described. Focal symptoms of stroke include the following: Weakness or paresis that may affect a single extremity, one half of the body, or all 4 extremities Facial droop Monocular or binocular blindness Blurred vision or visual field deficits Dysarthria and trouble understanding speech Vertigo or ataxia, Aphasia

Subarachnoid hemorrhage Symptoms of subarachnoid hemorrhage may include the following: Sudden onset of severe headache Signs of meningismus with nuchal rigidity Photophobia and pain with eye movements Nausea and vomiting Syncope - Prolonged or atypical

Approach Considerations
The treatment and management of patients with acute intracerebral hemorrhage depends on the cause and severity of the bleeding. Basic life support, as well as control of bleeding, seizures, blood pressure (BP), and intracranial pressure, are critical. Medications used in the treatment of acute stroke include the following: Anticonvulsants - To prevent seizure recurrence Antihypertensive agents - To reduce BP and other risk factors of heart disease Osmotic diuretics - To decrease intracranial pressure in the subarachnoid space Management begins with stabilization of vital signs. Perform endotracheal intubation for patients with a decreased level of consciousness and poor airway protection. Intubate and hyperventilate if intracranial pressure is elevated, and initiate administration of mannitol for further control. Rapidly stabilize vital signs, and simultaneously acquire an emergent computed tomography (CT) scan. Glucose levels should be monitored, with normoglycemia recommended.[28] Antacids are used to prevent associated gastric ulcers. Currently, no effective targeted therapy for hemorrhagic stroke exists.

Medication Summary
Medications used in the treatment of acute stroke include anticonvulsants such as diazepam, to prevent seizure recurrence; antihypertensive agents such as labetalol, to reduce blood pressure (BP) and other risk factors for heart disease; and osmotic diuretics such as mannitol, to decrease intracranial pressure in the subarachnoid space. As previously mentioned, the treatment and management of patients with acute intracerebral hemorrhage depends on the cause and severity of the bleeding. However, there is currently no effective targeted therapy for hemorrhagic stroke.

Autonomic dysreflexia (AD) is a syndrome of massive imbalanced reflex sympathetic discharge occurring in patients with spinal cord injury (SCI) above the splanchnic sympathetic outflow (T5-T6). This condition represents a medical emergency, so recognizing and treating the earliest signs and symptoms efficiently can avoid dangerous sequelae of elevated blood pressure. SCI patients, caregivers, and medical professionals must be knowledgeable about this syndrome and its management. Physical Examination A patient with AD may have 1 or more of the following findings on physical examination: Sudden, significant rise in systolic and diastolic blood pressure Profuse sweating above the level of lesion - Especially in the face, neck, and shoulders; rarely occurs below the level of the lesion because of sympathetic cholinergic activity Goose bumps above, or possibly below, the level of the lesion Flushing of the skin above the level of the lesion - Especially in the face, neck, and shoulders; this is a frequent symptom Blurred vision Spots in the patient's visual field Nasal congestion A common symptom With regard to the first item above, the sudden rise in blood pressure in AD is usually associated with bradycardia.