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ABSTRACT
Although thyroid dysfunction will develop in
more than 12% of the US population during
their lifetimes, true thyroid emergencies are
rare. Thyroid storm and myxedema coma are
endocrine emergencies resulting from thyroid hormone dysregulation, usually coupled with an acute illness as a precipitant.
Careful assessment of risk and rapid action,
once danger is identified, are essential for
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Thyroid Storm
Thyrotoxic crisis or thyroid storm is a rare
but life-threatening exacerbation of thyrotoxicosis. The incidence of thyroid storm has been
noted to be less than 10% of patients hospitalized for thyrotoxicosis.9 Thyroid storm is
more common in women than in men (10%
vs 2%) and occurs most commonly between
the ages of 20 and 49 years.5 Anyone with
untreated hyperthyroidism is at risk of thyrotoxic crisis, but a precipitating event such as
stroke, infection, trauma, or diabetic ketoacidosis usually occurs (see Table 3). Thyrotoxic
crisis may also be precipitated by surgery, particularly on the thyroid; radioiodine treatment
in a patient with unmanaged hyperthyroidism; noncompliance with antithyroid medications; or alcohol abuse.1,5 Individuals being
treated with certain medications are also at
higher risk of thyroid storm; these medications include nonsteroidal anti-inflammatory
Conventional Units
SI Units
0.55.0 IU/mL
0.55.0 mIU/L
70195 ng/dL
1.13.0 nmol/L
T3
Total serum
T4
Free serum
0.92.4 ng/dL
1231 pmol/L
Total serum
512 mcg/dL
64155 nmol/L
Abbreviations: IU, international units; T3, triiodothyronine; T4, thyroxine; TSH, thyroid-stimulating hormone.
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Class/Action
Function
Dose, Delivery
Adverse Effects,
Monitoring
600-mg loading,
then 200300
mg every 6 h
PO/NG tube/PR
Rashes, arthralgias,
fevers, benign
transient leukopenia,
hepatotoxicity
Potassium
iodide
saturated
solution
Stable iodide
5 drops PO every
6 h (38-mg
iodide per drop)
Hypersensitivity
reactions, salivary
gland swelling,
metallic taste
Methimazole
could be
used first, instead of PTU,
if severe,
but not lifethreatening
thyrotoxicosis
Thioamide
20 mg PO every
6h
Eventually dosed
daily
Rashes, arthralgias,
fevers, benign
transient leukopenia,
less hepatotoxicity
than PTU
Propranolol
-adrenergic
blocker
40-80 mg PO
every 4 h, or
2 mg IV every
4h
Nausea, vomiting,
bradycardia
Decrease peripheral
conversion of T4 to T3,
treat relative adrenal
insufficiency, promote
vasomotor stability,
antipyretic
Dexamethasone:
2 mg every 6
h 48 h, then
taper
Hyperglycemia
Dexamethasone
or
hydrocortisone
Start 1 h after
thioamide
Glucocorticoid
Hydrocortisone:
100 mg every
8h
Abbreviations: IV, intravenous; NG, nasogastric; PO, by mouth; PR, by rectum; PTU, propylthiouracil; T3, triiodothyronine; T4, thyroxine.
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Treatment
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Myxedema Coma
Myxedema coma is the end stage of untreated
or inadequately treated hypothyroidism, and
it, like thyroid storm, may be precipitated by
acute events, such as cerebrovascular accident,
myocardial infarction, infection, GI bleeding,
or trauma (see Table 4). Excessive hydration,
sedatives, narcotics, and potent diuretics also
may be precipitating factors.4,14 Other medications and medication factors that increase the
risk of myxedema coma include amiodarone,
lithium, phenytoin, and lack of adherence to
thyroid replacement therapy.5 The incidence
rate is estimated to be as low as 0.22 per million people per year,10 with the most common
presentation in hospitalized elderly women
with a long history of hypothyroidism.10,15
Eighty percent of women affected by this condition are older than 60 years, although it can
occur in younger patients and also in pregnant
women.10 Cases frequently present in the winter months, leading to the belief that cold
weather may lower the threshold for those
who are at risk of myxedema coma.10,15
Signs and Symptoms
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Class/Action
Synthetic
thyroxine
Function
Dose, Delivery
200-500 mcg IV/NG
tube for loading
dose, then 50 mcg
IV daily
Replacement
Adverse Effects,
Monitoring
Potential to
precipitate
Myocardial
infarction in high
doses
Cardiac monitoring
Liothyronine (T3)
Synthetic
triiodothyronine
Replacement
Arrhythmias, cardiac
monitoring
Hydrocortisone
glucocorticoid
50100 mg IV every
68 h 48 h or
until adrenal
suppression ruled
out, then taper
Hyperglycemia,
hypertension
Glucose and
blood pressure
monitoring
Marietta is an elderly, obese woman with medical history significant for type 2 diabetes, who
underwent open reduction and internal fixation
of a displaced left humerus fracture. Marietta
was hemodynamically stable throughout the
surgery, but upon completion and reversal of
sedation, she remained apneic and unresponsive. After treatment with naloxone, she
responded with shallow breathing and intermittent apnea, prompting resumption of ventilatory support. Although hypothermia was being
reversed with a forced air-warming device,
Mariettas laboratory test results showed normal electrolyte levels, absent ketones, and
normal blood gas. At this time, her blood
pressure was down to 75/50 mm Hg, prompting initiation of dopamine infusion. Her blood
pressure improved and 12-lead electrocardiogram failed to reveal any ischemic changes.
Thyroid function profile revealed T3, 0.30 ng/
mL; T4, 1.25 ng/dL; free T4, 0.85 ng/dL; and
TSH, 180 mU/L.
Marietta was treated with thyroid hormone
replacement and ongoing supportive care.
Within 6 hours, she was exhibiting regular
spontaneous respiratory effort and responding
to commands.17 Her blood pressure improved,
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Conclusion
Thyroid storm and myxedema coma are endocrine emergencies that occur infrequently but
can carry a high risk of mortality. These
patients require admission to the intensive care
unit because they need frequent monitoring
and aggressive intervention. Critical care nurses
can play a key role in early recognition of signs
and symptoms of thyroid storm and myxedema
coma, allowing for prompt intervention that
will limit the risk of morbidity and mortality.
REFERENCES
Thyroid Storm
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