Thyroid Emergencies

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Thyroid Emergencies

• Written by Mick Svoboda D.O.
• Presented by Dr. Shiley M.D.

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Review of thyroid hormone regulation
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hyperthyroidism

• Elevated free T4 levels Low or elevated TSH

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etiology

• Primary
• Graves disease
• Toxic multinodular/ nodular goitor
• Secondary
• Pituitary adenoma
• Thyroiditis
• Silent
• Subacute
• Pospartum
• Radiation thyroiditis

• Nonthyroidal diease
• Ectopic thyroid tissue
• Metastatic thyroid CA
• Drug induced
• Lithium
• Amiodarone
• Iodine (including contrast agents)

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Signs/symptoms

• Signs
• Weakness/fatigue
• Heat intolerance/sweating
• Nervousness
• Weight loss
• Tremor
• Increased defecation
• Menstrual abnormalities

• Symptoms
• Goiter
• Opthalmopathy
• Lid lag
• Warm, moist skin
• Muscle weakness
• Tachycardia
• Systolic Htn
• Widened pulse pressure
• hyperreflexia

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Thyroid Storm

• Hypermetabolic state 2 to hyperthyroidism
• Clinical diagnosis with empiric treatment
• Included in differential
• Sepsis
• Heat stroke
• malignant hyperthermia
• Delirium tremens
• Pheochromocytoma

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Precipitants of thyroid storm

• Infection
• Trauma
• DKA
• MI
• Surgery
• Iodine
• Ingestion of thyroid hormone

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Clinical presentation

• Classic symptoms
• Fever
• Sinus tachycardia/SVT out of proportion for fever
• GI symptoms
• AMS
• Additional sxs of hyperthyroidism

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labs

• Thyroid studies may not always be available or
  reliable.
• Many studies have shown that thyroid hormone
  levels are similar to that of patients with
  uncomplicated or symptomatic hyperthyroidism.
• Nonspecific findings
• Leukocytosis
• Hyperglycemia
• Elevated liver enzymes

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Treatment

• ABCs
• Prevent peripheral effects
• Propanolol 1mg IV Q5-15 min for max of 5mg or
  esmolol if contraindications to propanolol.
• Decrease hormone synthesis
• PTU- 600-1000mg PO, then 200-250mg Q4h
• Methimazole- 40mg PO, then 25mg Q6h

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Treatment (cont)

• Decrease hormone release (give 1 hour after PTU
  so that hormone synthesis is not increased)
• Iodine- potassium iodide 5 drops PO Q6h or
  lugols solution 8-10 drops PO Q6h
• Lithium
• Cooling blankets for fever
• Admit to appropriate monitored floor

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Hypothyroidism

• Low free T4 elevated or low TSH

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etiology

• Primary
• Hashimoto thyroiditis
• After surgery/ablation therapy
• Iodine deficiency
• Thyroiditis
• Subacute
• Silent
• Postpartum
• congenital

• Secondary
• Pituitary defect
• Tertiary
• Hypothalamic defect
• self limited and often followed by transient
  hyperthyroid state

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Signs/symptoms

• Signs
• Fatigue
• Weight gain
• Cold intolerance
• Depression
• Menstrual irregularities
• Infertility
• Muscle cramps

• Symptoms
• Hoarseness
• Bradycardia
• Nonpitting edema
• Periorbital
• Pretibial
• Loss of hair on outer 3rd of eyebrow
• Delayed relaxation of reflexes.

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Myxedema coma

• Life threatening decompensation in pt with
  longstanding hypothyroidism
• Hypometabolic state

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Precipitants of Myxedema coma

• Infection
• Cold exposure
• Drugs
• Sedatives
• Lithium
• Amiodarone
• Trauma
• Stroke
• CHF
• Inadequate thyroid supplementation

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Clinical presentation

• Vitals temp often lt 90 F, 50 have BP lt100/60
• Cardiac bradycardia
• Pulm hypoventilation, ?PO2 ?PCO2
• Metabolic hyponatremia, hypoglycemia
• Neuro AMS (confusion ? coma)
• Skin nonpitting edema (periorbital, pretibial)

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Diagnostics

• Thyroid functions
• TSH often gt 60, ? total and free T4, ? T3
• BMP
• hyponatremia, hypoglycemia
• EKG
• bradycardia, prolonged QT, low voltage
• ABGs
• ?PO2 ?PCO2
• If diag is suspected treat empirically

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Treatment

• ABCs
• Warming in case of hypothermia
• Thyroid hormone replacement
• Initial bolus (300-500mcg slow IV) Day 1 only
• Followed by 50-100mcg/daily
• Glucocorticoids
• 100mg hydrocortisone IV
• Recommended in order to prevent adrenal crisis in
  pt with unexpected AI.
• Correct metabolic abnormalities
• Na, K, or glucose
• Admit to the appropriate monitored floor.