THYROID EMERGENCIES

Ambika Rao, M.D.

CASE HISTORY
A 44 yr old female with 2 mths of SOB on exertion, fatigue, increased appetite, diarrhea, 10lb weight loss and heat intolerance. 2 weeks ago she developed palpitations and cough. Has amenorrhea for 8mths.

PHYSICAL EXAMINATION
O/E thin, anxious woman with T-36c, HR140/min, BP130/70. no exophthalmos, thyroid is enlarged diffuse with bruit. chest is normal. cardiac exam tachycardia and 2/6 systolic murmur, liver edge is felt without tenderness. tremor present in the hands, brisk reflexes.

LABORATORY FINDINGS
H/H-low with microcytosis FT4-9ng/dl FT3-4ng/dl TSH-<0.1 ast161u/l alk-p 288u/l lactic acid-high anion gap-19

THYROID EMERGENCIES
Thyroid storm Myxedema coma

THYROID STORM
decompensated hyperthyroid state underlying illness can precipitate storm end organ damage is seen but blood levels may not be any higher early, prompt therapy can reverse storm Incidence 10% of hospitalized patients with hyperthyroidism Mortality is 20-30%

Burch and Wartofsky criteria

temperature (99->104) 5-30points mental status change (mild-severe) 10-30 cardiac dysfunction
tachycardia (90->140) 5-25 points CHF (mild-severe) 5-15 points A-fib 10 points precipitating event 10 points >45 points thyroid storm

HYPERTHYROIDISM
Causes
Graves disease/autoimmune thyroiditis subacute thyroiditis/silent thyroiditis toxic MNG toxic adenoma exogenous ingestion iodine excess states pituitary tumor, struma ovarii

HYPERTHYROIDISM
Clinical Features
wt loss with good appetite heat intolerence,sweating,moist skin hyper defecation, nocturia,polymenorrhagia palpitations,dyspnea, angina tremor,muscle weakness anxiety, insomnia, emotional lability eyes-exophthalmos, lid lag goiter

THYROID STORM
Clinical Features
high fever CHF, arrhythmia diarrhea, vomiting, LFT elevation agitation, delirium, AMS, myopathy, stupor, coma

DIAGNOSIS
Lab
TSH T4, T3, antibodies, ESR chemistry-CBC,cholestrol

Radiology
radioactive iodine uptake RAI scan/TC scan

TREATMENT OF STORM
admit and close clinical monitoring with supportive measures specific treatment-antithyroid medication treatment of precipitating cause treatment of underlying cause

THYROID STORM TREATMENT

Antithyroid medications
Propylthiouracil-preferred
200-400mg q6-q8hr

iodine-prevents release of hormone to be given 1hr after PTU

sodium iodide iv 1-2g/day,SSKI 5drops q6hr

beta blockers to prevent peripheral affects

propranalol 1-5mg iv/20-40mg q4hr

glucocorticoids-hydrocortisone 100mg q6hr plamapheresis, PD, binding resins to remove large quantities of hormone (cholestyramine) supportive care

HYPERTHYROIDISM
Treatment
Depend on cause Graves disease
antithyroid medication radioactive iodine ablation surgery

MYXEDEMA COMA
severe hypothyroidism inability to handle endogenous or exogenous stress coma may or may not be present lethal with mortality rates of 50-75% Precipitating illness present

Precipitating factors for myxedema coma

hypothermia CVA, CHF infection drugs-anesthesia, sedatives, tranquilizers, narcotics, amiodarone, lithium GI bleed trauma metabolic- hypoglycemia, hyponatremia, acidosis, hypercalcemia, hypoxia, hypercapnia

HYPOTHYROIDISM
Causes
Secondary causes
pituitary tumor/infiltration surgery radiation

Primary hypothyroidism
Hashimotos thyroiditis surgery RAI radiation

HYPOTHYROIDISM
Clinical features-symptoms
weight gain, fatigue, cold intolerance, constipation, menorrhagia, depression, mental slowing, muscle cramps, parasthesias

HYPOTHYROIDISM
Clinical Features-signs
hypothermia bradycardia, increased diastolic HTN cardiomegaly, pericardial effusion enlarged tongue carotenemia , periorbital edema ,dry skin ileus ataxia, apathy, psychosis, obtundation delay in relaxation of reflexes

HYPOTHYROIDISM
Diagnosis
TSH in primary hypothyroidism T4 antibodies other

MYXEDEMA CRISIS
Clinical features
hypoventilation hypo metabolism hypothermia hypo responsiveness hyponatremia hypoadrenalism hypoglycemia hypotension hypotonia hypothyroidism

MYXEDEMA CRISIS
Management

Support ventilation External warming can precipitate hypotension Avoid sedation, lower med doses Screen for infection or other precipitating cause and treat Monitor electrolytes and use fluids cautiously Hydrocortisone 100mg iv q6hr L-thyroxine 100-500mcg iv, 50-100mcg/day iv consider L-T312.5-25mcg/day Switch to oral therapy

HYPOTHYROIDISM
Management
L-Thyroxine 1.6mcg/kg/day in otherwise healthy patients in patients age>60 or if CAD present, start at 25mcg/day and slowly increase L-T3-controversial recheck levels in 6 weeks.