Thyroid Emergencies

Heidi Chamberlain Shea, MD

Endocrine Associates of Dallas

Thyroid Trivia
Largest endocrine gland
20 grams in adult
Each lobe
2-2.5cm in width and
thickness
4cm in height

Isthmus
0.5cm thick
2cm height and width

Named for the

relationship to the
laryngeal thyroid cartilage
Resembles a Greek shield

Thyroid Hormone Synthesis

Iodide trapping
Oxidation of iodide and
iodination of thyroglobulin
Coupling of iodotyrosine
molecules within
thyroglobulin
(formation of T3 and T4)
Proteolysis of
thyroglobulin
Deiodination of
iodotyrosines
Intrathyroidal
deiodination of T4 to T3

Thyroid Hormones

T4

T3

T4 ( Tetraiodothyronine )
T3 ( Triiodothyronine ) , Reverse T3

Goals of Discussion
Hypothryoidism
Clinical symptoms
Myxedema Coma
Definition
Treatment

Hyperthryoidism
Clinical symptoms
Thyroid Storm
Definition
Treatment

Hypothyroidism
Symptoms
Nervous system
Forgetfulness and
mental slowing
Paresthesias
Carpal tunnel
Ataxia and decreased
hearing
Tendon jerk slowed
with prolonged
relaxation phase

Cardiovascular
Bradycardia
Decreased cardiac
output
Pericardial effusion
Reduced voltage on
EKG and flat T waves
Dependent edema

Hypothyroidism
Symptoms
Gastrointestinal
Constipation
Achlorhydria with
pernicious anemia
Ascitic fluid with high
protein

Renal
Reduced excretion of water
load
Hyponatremia

Decreased renal blood flow

and glomerular filtration

Pulmonary
Responses to hypoxia and
hypercapnia are decreased
Pleural effusions high
protein

Musculoskeletal

Arthralgia
Joint effusions
Muscle cramps
CK can be elevated

Anemia
Normochromic normocytic
Megaloblastic
Pernicious anemia

Hypothyroidism
Symptoms
Skin and hair
Loss of lateral eye brows
Dry, cool skin
Facial features
Coarse and puffy

Orange skin
Carotene

Reproductive system
Menorrhagia from
anovulatory cycles
Hyperprolactinemia
No inhibition of thyroid
hormone

Metabolism
Hypothermia
Intolerance to cold
Increased cholesterol and
triglyceride
Decreased lipoprotein
receptors

Weight gain

Myxedema Coma
Diagnosis
Altered mental status
Decreased orientation
Increased lethargy
Confusion/psychosis
May be secondary to

Stroke
Medication effect
Sepsis
CO2 narcosis

Myxedema Coma
Diagnosis
Defective
thermoregulation
Normal body temperature
with sepsis

Age
Most are elderly
Decreased ability to
compensate

Precipitating illness or
event
Exclude pulmonary or
urinary tract source
Trauma
Stroke
Hypoglycemia
Hypothermia
CO2 narcosis
Diuretics
Sedatives
Tranquilizers
Drug overdose

Myxedema Coma
Management
When in doubt, treat
Mortality 30-40%

ICU setting
Lab tests
TSH, T4, T3-uptake, Cortisol, CBC with diff and
routine chemistries
Blood, sputum and urine cultures
WBC may not be elevated
Bands present of other concerning finding, empiric treatment
is appropriate

Myxedema Coma
Management
Body temperature support
Poikilothermic
No aggressive warming
Vasodilatation= vascular collapse

Passive warming

Respiratory support
Intubation may be needed
If HCT <30%, transfuse
Provide adequate perfusion and oxygen carrying capacity

Myxedema Coma
Management
Cardiovascular support
Fall in blood pressure is ominous
Look for GI bleed, MI, over diuresis or iatrogenic
vasodilatation

Endocrine support
Hydrocortisone 100 mg Q8 hrs
Treat possible coexisting primary or secondary
adrenal insufficiency
Stop once cortisol level is confirmed to be normal

Myxedema Coma
Management
Thyroid hormone therapy
300-500 ug IV Levothyroxine x1
50-100 ug IV Qday
Lower doses for smaller people or older at risk for
cardiac events
IV to bypass poor absorption in the bowel

Alternately give T4 and T3 due to decreased

T3 conversion
200-300 ug T4 then 50 ug/day
5-20 ug T3 then 2.5-10 ug Q8 hrs

Myxedema Coma
Management
Addition of
Levothyroxine causes
Increase in cardiac index 12 days
TSH falls 32% in 24 hrs
Serum T3 levels increased
on 3rd day
Reversal of blunted
ventilatory responses 7
days

Myxedema Coma
Management
Obtain Free T4- 3 days after initiation of
therapy to make sure it is increasing
Adjust to normalize value

Once tolerating PO can change to oral

therapy
Increase IV dose by 40% for oral dosing
ie: IV 100 mcg then 140 mcg PO

Hyperthyroidism

Hyperthyroidism
Symptoms

Nervousness/Anxiety
Weight loss
Increased hunger
Heat intolerance
Cardiac
Atrial fibrillation
Palpitations

Increased stool frequency

Decreased concentration

Weakness
Fatigue
Decreased sleep
Irritablity
Change in menstrual
patterns
Infiltrative orbitopathy
Exopthalmos

Goiter
20% elderly no goiter
3% normal size

Hyperthyroidism
Cardiac
Sinus tachycardia
15% atrial fibrillation
Increased cardiac
output 2-3 times
normal

Nervous system
Diaphoresis
Tremor

Hyperthyroidism
Increased metabolic rate
Increased blood flow to tissues by
vasodilatation
T3 affects smooth muscle tone

Systemic vascular resistance is decreased by

50%
Decreased diastolic blood pressure
Increased rate and force of cardiac contraction

Increased erythropoietin = increased blood

volume

Hyperthyroidism
Lab Tests
TSH
Free T4
If done by RIA can be falsely
elevated
Gold standard equilibrium
dialysis

T4 and T3 uptake
T3
Thyroid stimulating
immunoglobulin (TSI AB)
TSH suppressed with
increase in T3 and T4

Thyroid Storm
Diagnosis
Decompensation of function due to symptoms
Hyperthermia
CNS effects
Delirium, psychosis, coma, seizure

Cardiac
Tachycardia
Heart failure
Abnormal rhythm

GI/Liver dysfunction
Jaundice
Diarrhea, nausea, vomiting and abdominal pain

Hyperthyroidism
Treatment
B-adrenergic blockade
Use cautiously in
asthmatics and diabetics
Improves

Tachycardia
Widens pulse pressure
Decreases palpitations
Anxiety
Sweating

Propranolol
Some decrease in T4 to
T3 conversion
20-40 mg Q4-6hrs

Atenolol or Metoprolol
Longer acting

Hyperthyroidism
Treatment
Thionamide medications
Block the thyroid hormone synthesis by
blocking organification of iodine
Propylthiouracil (PTU)
Blocks peripheral conversion of T4 to T3 in liver and
kidney
300-600 mg Q8 hrs

Methimazole (Tapazole)
30-60 mg Q8hrs, BID or QD

Thyroid Storm
Management

ICU setting
Mortality of 20-30%
Obtain thyroid function tests
Load PTU oral 1000 mg x1
then 200-250 Q4 hrs.
Rectal administration

Use Tapazole 30 mg Q6hrs

Rectal administration

Side Effects
Rash, arthralgia, serum
sickness, abnormal liver
function tests and
agranulocytosis

Sodium ipodate and

iopanoic acid
Radiographic contrast
agents
Potent inhibitors of T4 to T3
conversion
Structurally similar to
thyroxine
1 gram daily
Decrease T3 in 24-48
hours
Continue for 7-14 days

Thyroid Storm
Management
Inorganic iodine
Blocks thyroid hormone release
Lugols solution (8 drops) or saturated solution of
potassium iodide (SSKI) (6 drops) Q6 hrs.
Can dilute and give as a retention enema

Give iodine one hour after thionamides

Lithium

Patients with iodine allergy

300 mg Q6 hrs
Titrate to level of 1 mEq/L
Renal and neurological toxicity impair lithiums
usefulness

Thyroid Storm
Management
Corticosteroids
Decrease secretion of
thyroid hormone and
decrease T4 to T3
conversion
Hydrocortisone 100
mg Q8 hrs
Dexamethasone 2 mg
Q6 hrs
Use for 2 weeks

Thyroid Storm
Management
B-adrenergic blockade
Need higher doses
Propranolol 0.5 to 1.0 mg initially with
monitoring up to 2-3 mg in 1 minutes
60-80 mg oral every 4 hours

Esmolol loading 250-500 g/kg

50-100 g/kg/minute

Can use diltiazem and guanethidine

Asthma and heart failure
With tachyarrhythmia can use loading propranolol

Thyroid Storm
Management
Hyperthermia
Cooling blankets
Acetaminophen
Avoid aspirin
Can displace thyroid hormones
from binding proteins

Fluids 3-5 liters per day

Include glucose and thiamine
Depletion of liver glycogen and
thiamine deficiency

Congestive heart failure

Diuretics
Digoxin
Requires higher doses in thyroid
storm

Thyroid Storm
Management
Look for precipitating event
All febrile patients should be cultured
Unless source found, no empiric treatment
needed

Once stable and T4 levels are decreasing

can decrease dosing of thionamides

Hyperthyroidism
Limit activity
In patients with heart disease
Increased risk of heart failure

Young patients
High output failure
Increased circulating volume

During exercise not able to increase LVEF

Not able to further decrease SVR

Conclusion
Myxedema coma
Critical samples
Passive warming
Load Synthroid
Daily IV

Start Hydrocortisone
Look for inciting event

Thyroid storm
Critical samples
Control heart rate
B-blockade
Calcium channel
blockade

Thionamide therapy
Look for inciting event