PRESKAS IGD

THYROID STORM


Oleh: Mira Puspita
Primary Survey
• A : clear, paten
• B : spontan, simetris, RR 32x/mnt, Sa02 97%
• C : nadi reguler, teraba kuat, 130x/mnt, TD
150/100 mmHg, akral hangat, CRT<3’’
• D : Alert
• GDS : 157
Data Dasar
• Nama : Ny. S
• Usia : 60 tahun
• Alamat : Empang
• Pekerjaan : IRT
• Pembiayaan : Jamkesmas
• Tanggal datang : 27 Maret 2014 pk. 17.20 WITA

• KU : Berdebar-debar yang semakin menghebat
sejak 1 hari SMRS
Tatalaksana Awal
• Pasien ditempatkan di critical care (P1)
• O2 nasal kanul 4 lpm
• IVFD RL 500 cc guyur
• EKG
• Cek DL, GDS, Elektrolit


Secondary Survey
S:
• Berdebar-debar yang semakin menghebat sejak 1 hari
SMRS. Sebelumnya mempunyai riwayat berdebar sejak
3 bulan SMRS. Terasa sesak sejak 1 hari SMRS.
• Lemah sejak 3 bulan terakhir
• Mengaku mata menonjol dan sering berkeringat kurang
lebih 2 bulan terakhir
• Nafsu makan menurun, BB menurun 6 kg dlm 2 bln
• Demam dan batuk berdahak sejak 2 hari SMRS
• Diare sejak 2 hari SMRS, 4x/hari, air (+), ampas (+)
• Tidak bisa tidur sejak 2 hari SMRS





S:
• BAK dalam batas normal
• Menopause (+) sejak 7 tahun yg lalu
• Riwayat gondok sebelumnya (-)
• Riwayat HT (-), DM (-), riw. Sakit Jantung (-),
Riw. Stroke, trauma, koma, kejang, operasi
disangkal
• Riw. Keluarga: HT (-), DM (-)
Pemeriksaan Fisik
• KU : Tampak sakit berat, terpasang NK,
E4V5M6, TD 142/111 mmHg, Nadi
130x/mnt reguler dan kuat, RR 36x/mnt,
suhu 39
0
C
• Kepala : deformitas (-), nyeri tekan (-), mukosa
kering
• Leher : Pembesaran KGB (-), tiroid teraba
membesar konsistensi kenyal, dapat
digerakkan, tidak nyeri, bruit (-)
• Mata : konjungtiva pucat -/- , sklera ikterik -/- ,
RCL +/+, RCTL +/+, diameter pupil 3 mm,
tampak exoptalmus +/+, Lid retraction +/+

• Jantung : S1-S2 reguler, murmur (-), gallop (-)

• Paru:
– Simetris saat statis dan dinamis, retraksi sela iga (-)
– Fremitus paru kanan=kiri
– Batas paru dalam batas normal
– Vesikuler +/+, wheezing -/-, rhonki -/-

• Abdomen : supel, datar, nyeri tekan (-), shifting dullness (-
),turgor normal, Hati dan Limpa tidak membesar, BU (+)

Secondary Survey
• Ekstremitas : akral hangat, CRT < 3’’,
sianosis (-), edema (-),
tremor pada kedua tangan


Secondary Survey
HASIL LABORATORIUM
ELEKTROLIT HASIL NORMAL
Natrium 135,16 135,37 - 145,00 mmol/L
Kalium 3,56 3,48 – 5,50 mmol/L
Clorida 104,99 96,00 – 106,00 mmol/L
Calsium Ion 1,67 1,10 – 1,35 mmol/L
Darah Rutin HASIL NORMAL
Hb 15,5 13,2-17,3
Ht 34,2 40,0-52,0
Leukosit 13000 3600-11000
Trombosit 212.000 150.000-436.000
Granulosit 68,5 1,8-7,7
Limposit 24,2 25,0-40,0
Mid 15,9 0,0-14,0
Kesan : Leukositosis, Granulositosis, Hipercalsemia
HASIL EKG
• Irama : Sinus Takikardi
Laju : 123x/mnt
Axis : Normoaxis

Gel.P : Durasi 0,08 s, tinggi 1 mm
Pmitral (-), P pulmonal (-)
Interval PR : 0,12 s
Gel.Q : Q patologis (-)



• Komplex QRS :
–Durasi komplex QRS 0,12 s
–R V5 + S V1 < 35 kk
•Segmen ST : isoelektrik, ST depresi (-), ST elevasi (-)
•Gel. T : T inverted II, III, aVF , v2-v5
•Interval QT : 0,28 s (memendek)
•Gel. U : negatif





Kesan : irama sinus takikardi, normoaxis, tidak ada hipertrofi ventrikel
kanan maupun kiri, terdapat gangguan iskemik pada inferior,
anteroseptal + lateral, gangguan elektrolit hipercalcemia

USG
USG
• Lobus dextra : nodul hiperechoik
• Lobus sinistra : nodul hipoechoik
• Kesan : SMNT susp ganas
BURCH & WARTOFSKY CRITERIA FOR
THYROID STORM
70
>45 highly suggestive of thyroid storm
25-45 suggestive of thyrotoxic storm
<25 unlikely
Working Diagnosis
• THYROID STORM
• DEHIDRATION
• ISKEMIK MIOKARD
Tatalaksana

• IVFD RL 500 cc guyur  30 tpm
• PTU 400 mg
• Propanolol 10 mg
• Inj. Dexametason 5 mg
• Lugol drop 5gtt  kosong
• Rawat ICU

Follow Up ICU
28/03/2014, j, 08.30
• Keluhan : masih berdebar-debar,
mencret (+)
• KU : lemah
• Kes : CM
• TD : 124/78, HR : 96x/m, T:37,5 C
P/
• O2 2-4 lpm
• Inf.RL 20 tpm
• Inj. Dexametason 3x1
• PTU 3 x 100 mg
• Propanolol 1x 10 mg
• PCT 3x1 tab
• Neodiaform 3x1
• Obs TTV
28/03/2014, j, 08.30
• Keluhan : masih berdebar-debar,
mencret (-)
• KU : lemah
• Kes : CM
• TD : 162/95, HR : 92x/m, T:37 C
P/
• O2 2-4 lpm
• Inf.RL 20 tpm
• Inj. Dexametason 3x1
• PTU 3 x 100 mg
• Propanolol 1 x 10 mg
• PCT 3x1 tab
• Amlodipin ext 5 mg
• Inj ondansentron 2 x 4 mg
• Obs TTV
TINJAUAN PUSTAKA
THYROID STORM
• Krisis Tiroid (Thyroid storm)
– Suatu keadaan hipertiroid yang mengalami
eksaserbasi sehingga mengancam kehidupan yang
ditandai dengan dekompensasi dari satu atau
lebih sistem organ dengan keadaan status
hipermetabolik.
Symptoms
• General symptoms
– Fever
– Profuse sweating
– Poor feeding and weight loss
– Respiratory distress
– Fatigue (more common in older adolescents)
• GI symptoms
– Nausea and vomiting
– Diarrhea
– Abdominal pain
– Jaundice
• Neurologic symptoms
– Anxiety
– Altered behavior
– Seizures, coma

Physical Finding

• Fever
– Temperature consistently exceeds 38.5°C.
• Excessive sweating
• Cardiovascular signs
– Hypertension
– Cardiac arrhythmia
• Neurologic signs
– Agitation and confusion
– Tremors, seizures
• Signs of thyrotoxicosis
– Orbital signs
– Goiter
Table Precipitants of Thyroid Storm
Systemic insult Cardiovascular insult
Infection Myocardial infarction
Trauma Cerebrovascular accidents
General surgery Pulmonary embolism
Hyperosmolar coma Obstetrics-related
Endocrinal insult Parturition
Diabetic ketoacidosis Eclampsia
Drug- or hormone-related Unknown etiology in up to 25% of cases
Withdrawal of thyroid medication
Iodine administration
Radioactive iodine theraphy
Ingestion of thyroid hormone
BURCH & WARTOFSKY CRITERIA FOR
THYROID STORM
MANAGEMENT
• Treatment aims are as follows:

• 1. Supportive care
• 2. Drug Therapy :
– Inhibition of thyroid hormone release
– Inhibition of new hormone production
– Peripheral -adrenergic receptor blockade
– Preventing peripheral conversion of T4 to T3



Supportive Care

General: oxygen, cardiac monitoring.

Fever: external cooling; acetaminophen, 325–
650 milligrams PO/PR every 4–6 h

Dehydration: IV fluids

Cardiac decompensation (atrial fibrillation,
congestive heart failure): rate control and
inotropic agent, diuretics, sympatholytics as
required.

Drug Therapy
• Antitiroid
– PTU (propylthiouracil) 400-600 mg stat PO,
• Iodine solution
– Lugol’s iodine 5 drops PO ; must give 1-2 hours
post PTU therapy
• Beta Blockers
• Propanolol 20-40 mg q 4 h
• Dexametason
– 2 mg iv

TERIMA KASIH




2. Inhibition of thyroid hormone release with thionamides
PTU, a loading dose of 600–1000 milligrams given PO and followed by 200–250
milligrams every 4 h. Total daily dose should be given: 1200–1500 milligrams/d. Drug
can be given via nasogastric tube or PR. (PTU is the preferred thionamide as it also
blocks peripheral conversion of T4 to T
3
.)

or
Methimazole, 40 milligrams given PO as loading dose and followed by 25 milligrams
every 4 h. Total daily dose should be given: 120 milligrams/d. If given PR, 40 milligrams
should be crushed in aqueous solution.
3. Inhibition of new thyroid hormone production (at least 1 h after step 2)
Lugol solution, 8–10 drops PO every 6–8 h.
or
Potassium iodide (SSKI), five drops PO every 6 hours.
or
IV iopanoic acid (Telepaque
®
), 1 gram every 8 h for first 24 h, then 500 milligrams
twice a day.

or
Ipodate (Oragrafin
®
), 0.5–3 grams/d PO (especially useful with thyroiditis or thyroid
hormone overdose).

or
Lithium carbonate (if allergic to iodine or agranulocytosis occurs with thionamides),
300 milligrams PO every 6 h (1200 milligrams/d) and subsequently to maintain serum
lithium at 1 mEq/L.
4. -adrenergic receptor blockade
Propranolol, IV in slow 1- to 2-milligram boluses, which may be repeated every 10 to 15
min until the desired effect is achieved. For less toxic patient, PO dose of 20 to 120
milligrams per dose or 160 to 320 milligrams/d in divided doses (contraindicated in
bronchospastic disease and congestive heart failure). Treat congestive heart failure before
starting propranolol (e.g., starting dobutamine).
or
Esmolol, 500 micrograms/kg IV bolus, then 50–200 micrograms/kg/min maintenance
(selective -adrenergic blocker).
or
Reserpine, 2.5–5.0 milligrams IM every 4–6 h, preceded by 1-milligram test dose while
monitoring blood pressure (use if -blocker contraindicated and congestive heart failure,
hypotension, and cardiac shock not present, see the Alternative Treatments section).
or
Guanethidine, 30–40 milligrams PO every 6 h (use if -blocker contraindicated and
congestive heart failure, hypotension, and cardiac shock not present, see the Alternative
Treatments section).
5. Preventing peripheral conversion of T4 to T
3


Hydrocortisone, 100 milligrams IV initially, then 100 milligrams three times/d until
stable (also for adrenal replacement due to hypermetabolism).
or
Dexamethasone, 2 milligrams IV every 6 h.
6. Treat precipitating event
All triggers of thyroid storm should be searched and treated accordingly (infection,
myocardial infarct, diabetic ketoacidosis, etc.).
7. Definitive therapy
Radioactive iodine ablation therapy or surgery may be necessary.