Thyroid Emergencies (quick review)

1 Aug

submitted by Amit Kumar, M.D.

 

THYROID STORM

-Risk factors:

Longstanding untreated thyroid issues (Grave’s, toxic multinodular goiter, solitary toxic adenoma), but more commonly surgery, trauma, infection, parturition, recent iodine load

 

-Diagnosis:

Hyperpyrexia, AMS, cardiac dysfunction (tachycaria, A-fib, CHF, etc.) in a patient with elevation of T4/3 and supression of TSH

 

-Treatment:

  • 1) Control increased adrenergic tone: B-blocker
    • PO: Propranolol 60-80mg q4-6h (monitor HR, BP)
    • IV: Esmolol 250-500mcg/kg followed by 50-100mcg/kg/min
  • 2) Block new hormone synthesis
    • PTU 200mg q4h (safe during pregnancy) or
    • Methimazole 20mg q4-6h
  • 3) Block further release of hormone
    • Iodine (1h post step 2, or else will be used to make more T4)
  • 4) Inhibit peripheral conversion of T4 -> T3
    • PTU,
    • steroids such as hydrocortisone 100mg q8h (also treats relative assoc. adrenal insufficiency)

 

 

MYXEDEMA COMA

-Risk factors:

Acute event (ex: MI, cold exposure, sedative drugs such as opioids) in poorly controlled hypothyroid patient, drug induce (ex: lithium, amiodarone)

 

-Diagnosis:

Depressed mental status + hypothermia, hyponatremia, and/or hypercapnia (due to hypoventilation); hx of thyroidectomy scar or recent radioiodine therapy

Primary (with high TSH) or central (with low TSH)

 

 

-Treatment:

  • 1) Thyroid hormone
    • Combined T4 (200-400mcg IV) and T3 (5-20mcg IV). Both are continued thereafter.
  • 2) Glucocorticoids (until concominant adrenal insufficiency is ruled-out)
    • Hydrocortisone 100mg q8h
  • 3) Supportive care
    • Non-dilute fluids (due to hyponatremia), passive rewarming, pressors (if hypotension doesn’t resolve)

 

 

References:

-Brunette DD, Rothong C. Emergency department management of thyrotoxic crisis with esmolol. Am J Emerg Med 1991; 9:232.

-Cooper DS, Daniels GH, Ladenson PW, Ridgway EC. Hyperthyroxinemia in patients treated with high-dose propranolol. Am J Med 1982; 73:867.

-Cooper DS, Saxe VC, Meskell M, et al. Acute effects of propylthiouracil (PTU) on thyroidal iodide organification and peripheral iodothyronine deiodination: correlation with serum PTU levels measured by radioimmunoassay. J Clin Endocrinol Metab 1982; 54:101.

-Jonklaas J, Bianco AC, Bauer AJ, et al. Guidelines for the treatment of hypothyroidism: prepared by the american thyroid association task force on thyroid hormone replacement. Thyroid 2014; 24:1670.

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