Thyroid storm....By: Dr. Sajid Mumtaz Sodhar

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Thyroid Storm Thyrotoxicosis crisis By: Dr. Sajid Mumtaz:

Thyroid Storm Thyrotoxicosis crisis By: Dr. Sajid Mumtaz

Thyroid Storm:

Thyroid Storm Thyroid storm ( thyrotoxic crisis) is rare but an acute,life threatening, hypermetabolic state of hyperthyroidism where all of the signs and symptoms are exaggerated. It can be life threatening but with quick response can be controlled and managed.

Triggers:

Triggers Trauma Infection Surgery

Triggers:

Triggers Sepsis Surgery Anesthesia induction Radioactive iodine (RAI) therapy Drugs ( anticholinergic and adrenergic drugs such as pseudoephedrine; salicylates ; nonsteroidal anti-inflammatory drugs [NSAIDs]; chemotherapy) Excessive thyroid hormone (TH) ingestion Withdrawal of or noncompliance with antithyroid medications Diabetic ketoacidosis Direct trauma to the thyroid gland Vigorous palpation of an enlarged thyroid Toxemia of pregnancy and labor in older adolescents; molar pregnancy

Pathophysiology:

Pathophysiology Thyroid storm is a decompensated state of thyroid hormone–induced, severe hypermetabolism involving multiple systems and is the most extreme state of thyrotoxicosis . The clinical picture relates to severely exaggerated effects of THs due to increased release (with or without increased synthesis) or, rarely, increased intake of TH.

Pathophysiology:

Pathophysiology Heat intolerance and diaphoresis are common in simple thyrotoxicosis but manifest as hyperpyrexia in thyroid storm. Extremely high metabolism also increases oxygen and energy consumption. Cardiac findings of mild-to-moderate sinus tachycardia in thyrotoxicosis intensify to accelerated tachycardia, hypertension, high-output cardiac failure, and a propensity to develop cardiac arrhythmias. Similarly, irritability and restlessness in thyrotoxicosis progress to severe agitation, delirium, seizures, and coma

Epidemiology :

Epidemiology Frequency (in USA) The true frequency of thyrotoxicosis and thyroid storm in children is unknown. The incidence of thyrotoxicosis increases with age. Thyrotoxicosis may affect as many as 2% of older women. Children constitute less than 5% of all thyrotoxicosis cases. Graves disease is the most common cause of childhood thyrotoxicosis and, in a possibly high estimate, reportedly affects 0.2-0.4% of the pediatric and adolescent population. About 1-2% of neonates born to mothers with Graves disease manifest thyrotoxicosis .

Mortality/Morbidity:

Mortality/Morbidity Thyroid storm is an acute, life-threatening emergency. The adult mortality rate is extremely high (90%) if early diagnosis is not made and the patient is left untreated. With better control of thyrotoxicosis and early management of thyroid storm, adult mortality rates have declined to less than 20%.

Differential Diagnoses :

Differential Diagnoses Anxiety Disorder: Panic Disorder Heart Failure, Congestive Hypertension Hyperthyroidism Pheochromocytoma Supraventricular Tachycardia, Atrial Ectopic Tachycardia

Thyroid Storm:

Thyroid Storm Treatment is largely symptomatic and etiology dependent Look back at the treatments in your hyperthyroid module Think also about the body’s functioning and the exaggerated symptoms of hyperthyroidism that would be manifested during thyroid storm

Dx::

Dx : Diagnosis is primarily clinical, and no specific laboratory tests are available. Burch and Wartofsky have published precise criteria and a scoring system for the diagnosis of thyroid storm based on clinical features.

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General symptoms Fever (Temperature consistently exceeds 38.5°C, pts: may progress to hyperpyrexia,temperature frequently exceeds 41°C). Profuse sweating Poor feeding and weight loss Respiratory distress Fatigue (more common in older adolescents) GI symptoms Nausea and vomiting Diarrhea Abdominal pain Jaundice [3] Neurologic symptoms Anxiety (more common in older adolescents) Altered behavior Seizures, coma

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Cardiovascular symtoms Hypertension with wide pulse pressure Hypotension in later stages with shock Tachycardia disproportionate to fever Signs of high-output heart failure Cardiac arrhythmia ( Supraventricular arrhythmias are more common, [ eg , atrial flutter and fibrillation], but ventricular tachycardia may also occur). Signs of thyrotoxicosis Orbital signs Goiter

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Diagnostic parameters Scoring points Thermoregulatory dysfunction Temperature °F (°C) 99–99.9 (37.2-37.7) 100–100.9 (37.8-38.2) 101–101.9 (38.3-38.8) 102–102.9 (38.9-39.2) 103–103.9 (39.3-39.9) >/= 104.0 (>/= 40.0) 5 10 15 20 25 30 Central nervous system effects Absent Mild (agitation) Moderate (delirium, psychosis, extreme lethargy Severe (seizures, coma) 0 10 20 30 Gastrointestinal-hepatic dysfunction Absent Moderate (diarrhea, nausea/vomiting, abdominal pain) Severe (unexplained jaundice) 0 10 20 Cardiovascular dysfunction Tachycardia (beats/minute) 90–109 110–119 120–129 130–139 >/= 140 5 10 15 20 25 Congestive heart failure Absent Mild (pedal edema) Moderate (bibasilar rales) Severe (pulmonary edema) 0 5 10 15 Atrial fibrillation Absent Present Precipitating event Absent Present 0 10 0 10

Scoring system: A score of 45 or greater is highly suggestive of thyroid storm; a score of 25–44 is suggestive of impending storm, and a score below 25 is unlikely to represent thyroid storm:

Scoring system: A score of 45 or greater is highly suggestive of thyroid storm ; a score of 25–44 is suggestive of impending storm , and a score below 25 is unlikely to represent thyroid storm

Thyroid Storm Management:

Thyroid Storm Management Patients with thyroid storm should be treated in an ICU setting for close monitoring of vital signs and for access to invasive monitoring and inotropic support, if necessary. Initial stabilization and management of systemic decompensation is as follows:

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Immediately provide supplemental oxygen, ventilatory support, and intravenous fluids. Dextrose solutions are the preferred intravenous fluids to cope with continuously high metabolic demand. Correct electrolyte abnormalities. Treat cardiac arrhythmia, if necessary. Aggressively control hyperthermia by applying ice packs and cooling blankets and by administering acetaminophen (15 mg/kg orally or rectally every 4 h). Promptly administer antiadrenergic drugs ( eg , propranolol ) to minimize sympathomimetic symptoms. Correct the hyperthyroid state. Administer antithyroid medications to block further synthesis of thyroid hormones (THs).

Storm Treatments:

Storm Treatments Treatments directed at thyroid gland and hormones Inhibition of new hormone synthesis with Thioamide drugs such as PTU and methimazole Inhibition of hormone release with Iodine & potassium iodide (Lugol’s solution) & Lithium carbonate

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Regarding the potential for severe liver disease in children due to PTU. The current recommendations (endorsed by the Endocrine Society) are to preferentially use methimazole in the pediatric population for treatment of Graves disease. The use of PTU in conditions of thyroid storm was not specifically addressed; however, the use of PTU may be preferred in this setting (TS) because of the ability of this drug to inhibit conversion of T4 to T3.

 Methimazole (Tapazole):

Methimazole ( Tapazole ) Inhibits synthesis of TH by preventing organification of iodide to iodine and coupling of iodotyrosines . At least 10 times more potent than PTU on a weight basis, it does not inhibit peripheral conversion of T4 to T3. May be used instead of PTU in thyroid storm if iodinated radiocontrast agents are used in conjunction to prevent the conversion of T4 to T3 or if the condition is not life-threatening. Comatose patients may require administration via NG tube because agent is available only as a PO preparation. In rare instances, it may be necessary to administer methimazole PR as an enema or suppository or IV after dissolving tablets in normal saline at a neutral pH and filtering the solution through a fine filter. PR and IV preparations should be made by the hospital pharmacy; it is essential to ensure sterility of IV preparations .

Lugol’s solution:

Lugol’s solution Also known as Lugol’s iodine, this oral solution is specifically indicated for patient’s with thyroid storm or preoperatively for a patient with hyperthyroidism It is a mix of iodine, potassium iodide and distilled water It is also used to enhance color and growth for coral in home aquariums !

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Potassium iodide, saturated solution (Pima, SSKI, Thyro -Block ) This agent is used to inhibit TH release from the thyroid gland. One mL of SSKI contains 1 g of potassium iodide or 750 mg of iodide ( ie , approximately 50 mg iodide/drop and 15 drops per mL ). Because of the viscosity, SSKI comes as 15 drops per mL rather than the usual 20 drops per mL. Strong iodine ( Lugol Solution ) Contains 100 mg potassium iodide and 50 mg iodine; provided 8 mg iodide/drop, 20 drops per ml.

Iodine compounds:

Iodine compounds Administer iodine compounds ( Lugol iodine or potassium iodide) orally or via a nasogastric tube to block the release of THs (at least 1 h after starting antithyroid drug therapy). If available, intravenous radiocontrast dyes such as ipodate and iopanoate can be effective in this regard. These agents are particularly effective at preventing peripheral conversion of T4 to T3.

Storm Treatments:

Storm Treatments Treatments directed at preventing hormone’s affects on the body Polythiouracil (PTU) Corticosteroids( Administer glucocorticoids to decrease peripheral conversion of T4 to T3. This may also be useful in preventing relative adrenal insufficiency due to hyperthyroidism. Beta blockers (most importantly Propanolol,if C/I, then B- selective;esmolol Amiodarone Plasmapheresis (life-saving measure in adult)

Propylthiouracil (PTU:

Propylthiouracil (PTU High-dose propylthiouracil (PTU) is preferred because of its early onset of action and capacity to inhibit peripheral conversion of T4 to T3. The US Food and Drug Administration (FDA) had added a boxed warning, the strongest warning issued by the FDA, to the prescribing information for PTU. Risk for severe liver injury and acute liver failure, some of which have been fatal. The boxed warning also states that PTU should be reserved for use in those who cannot tolerate other treatments such as methimazole , radioactive iodine, or surgery. PTU is considered as a second-line drug therapy, except in patients who are allergic or intolerant to methimazole , or for women who are in the first trimester of pregnancy.

Treatment Summary:

Treatment Summary Overall Goal: Reduce circulation thyroid levels and control symptom Beta blockers; decreases adrenergic hyperactivity (sympathetic outflow) Anti-thyroid: Thionamides , PTU (large amounts): prevents synthesis of the hormone Glucocorticoids : inhibit hormone production and decrease peripheral conversion from T4 to T3. Sodium iodide solution ( Lugol’s solution) : High levels of iodide will initially suppress release of thyroid hormone Treat cardiac symptoms, fever and hypertension

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Iodine preparations should be discontinued once the acute phase resolves and the patient becomes afebrile with normalization of cardiac and neurological status. Glucocorticoids should be weaned and stopped and the dose of thioamides adjusted to maintain thyroid function in the normal range. Beta-blockers may be discontinued once thyroid function normalizes . If the patient is given PTU during treatment of thyroid storm, this should be switched to methimazole at the time of discharge unless methimazole is contraindicated. If there is a contraindication for the use of methimazole , alternative methods to treat hyperthyroidism should be considered after discharge, such as radioactive iodine or surgery.

Nursing Functions:

Nursing Functions Initiate cardiac monitoring, have code supplies ready if cardiac symptoms worsen Monitor hemodynamic, respiratory & thermic parameters to ensure that therapies are working (homeostasis) Keep patient safe and re-orient if acutely confused or highly anxious Identify trigger and treat/remove

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Jasakallah khairan