Hyperthyroidism and

Thyroid Storm
Tintinalli Chapter 215
12/15/05

Prepared by Trent W. Smith

Lecture by Dr. Klien MD
 Normal Thyroid State
Synthesis and release of thyroid hormone
is controlled by TSH relaesed form the
anterior pituitary
TSH is controlled by the release of thyroid
releasing hormone (TRH) from the
hypothalmus and a negative feedback
loop to the pituitary
Thyroid hormone production s dependent
on adequate adequate iodine intake
 Normal Thyroid State
Thyroid hormone is reversible bound to
various proteins including thyronine-
binding globulin (TBG)
Free unbound portions are biologically
active
T4 is the predominant circulating hormone
T4 is deiodinated to t3
T3 is biologically more active than T4 but
has a shorter half-life
 Hyperthyroidism
Occurs in in all ages
Uncommon under the age of 15
10 xs more common in women (1/10,000)
Graves disease is the most common etiology
80% of cases in the U.S.
Common in the 3rd and 4th decades
Caused by autoimmune thyroid-stimulating antibodies
Associated with diffuse goiter, opthalmopathy, and
local dermopathy
 Hyperthyroidism
Toxic multinodular and toxic nodular
goiters are the next most common
etiologies
Usually occurs in older populations
Commonly with previous history of goiter
Often with milder symptoms of thyrotoxicosis
 Hyperthyroidism
Amiodarone-induced thyrotoxicosis (AIT)
Amiodarone is iodine rich and may cause
both hyper and hypothyroidism
Difficult to treat because of incomplete
understanding of mechanism
Two major forms exists
Type 1 occurs with a normal thyroid
Type 2 occurs with a abnormal thyroid
Tx. Varies based on the the type
 Hyperthyroidism
Hyperthyroidism resembles a state of
increased adrenergic activity despite a
normal or low serum cortisol level
Classic complaints include heat
intolerance, palpitations, weight loss,
sweating, nervousness, and fatigue
 Hyperthyroidism
Symptoms Signs
Weaknes Goiter/thyroid burit

Fatigue Hyperkinesis

Heat intolerance Opthalmopathy

Nervousness Lid retraction/stare

Increased sweating Lid lag

Tremors Tremor

Palpitations Warm moist skin

Weight loss Hyperreflexia

Hyperdefication Tachycardia/arrhythmia

Dyspnea Systolic hypertension

Menstrual abnormalities Widened pulse pressure

 Hyperthyroidism
Confirmed by thyroid function test
Elevated free T4 and Low TSH
In some cases of graves disease T4 may be
normal and TSH decreased but the patient
appears thyrotoxic
T3 level should be done to rule out T3
toxicosis
Hypothyroidism secondary to pituitary
adenoma will have elevated TSH levels
 Hyperthyroidism
Treatment
Palliative treatment of mild hyperthyroidism is
accomplished using B-blockers
Most commonly used is propanolol
Treatment of Graves diseases include long-
term use of antithyroid medications,
radioactive iodine, or subtotal thyroidectomy
Type I AIT is treated with methimazole and
potassium perchlorate
Type II AIT is treated with glucocorticoids
 Hyperthyroidism
Treatment cont.
Toxic multinodular goiter and solitary
adenomas may be treated with radioiodine
therapy
Thryoiditis is usually self limited and therapy
is rarely needed
 Thyroid Storm
A life threatening hypremetabolic state due to
hyperthyroidism
Mortality rate is high (10-75%) despite treatment
Usually occurs as a result of previously
unrecognized or poorly treated hyperthyroidism
Thyroid hormone levels do not help to
differentiate between uncomplicated
hyperthyroidism and thyroid storm
 Thyroid Storm
Preciptatnts of Thyroid Storm (tabel 215-4)

Infection Trauma

DKA MI

CVA PE

Surgery Withdrawal of thyroid

med
Iodine administration Palpation of thyroid
gland
Ingestion of thyroid Unknown etiology (20-
hormone 25%)
 Thyroid Storm
Clinical features
The most common signs are fever,
tachycardia out of proportion to the fever,
altered mental status, and diaphoresis
Clues include a history of hyperthyroidism,
exophthalmoses, widened pulse pressure and
a palpable goiter
Patients may present with signs of CHF
 Thyroid Storm
Clinical features cont.
Common GI symptoms include diarrhea and
hyperdefication
Apathetic thyrotoxicosis is a distinct
presentation seen in the elderly
Characteristic symptoms include lethargy, slowed
mentation, and apathetic facies
Goiter, weight loss , and proximal muscle
weakness also present
 Thyroid Storm
Diagnosis
Thyroid storm is a clinical diagnosis based
upon suspicion and treated empirically
Lab work is non specific and may include
Leukocytosis, hyperglycemia, elevated
transaminase and elevated bilirubin
 Thyroid Storm
Treatment
Initial stabilization includes airway protection,
oxygenation, fluids and cardiac monitoring
Treatment can then be divided into 5 areas:
General supportive care
Inhibition of thyroid hormone synthesis
Retardation of thyroid hormone release
Blockade of peripheral thyroid hormone effects
Identification and treatment of precipitating events
 Thyroid Storm
Drug Treatment of Thyroid Storm (table 216-6)
Decrease de novo synthesis:
Porpythiouracil 600-1000mg PO initially, followed by 200-250 mg q 4 hrs
Methimazole 40 mg PO initial dose, then 25 mg PO q6h
Prevent relases of hormone (after synthesis blockade intiated)
Iodine Iaponoric acid (Telepaque) 1 gm IV q8h for the first 24 h, then
500 mg bid or Potassium iodide (SSKI) 5 drops PO q6h or Lugol
solution 8-10 drops PO q6h
Lithuim 800-1200 mg PO every day
Prevent peripheral effects:
B-Blocker Propanolol (IV) titrate 1-2 mg q 5min prn (may need 240-480mg
PO q day) or Esmolol (IV) 500 mcg/kg IV bolus, then 50-200
mcg/kg per min maintenance
Guanethidine 30-40 mg PO q 6 h
Reserpine 2.5-5 mg IM q4-6h
Other consideration:
Corticosteroids Hydrocortisone 100 mg IV q 8 h or
dexamethosone 2 mg IV q 6 hr
Antipyretics Cooling blanket
acteaminophen 650 mg PO q 4-6h
 Thyroid Storm
Treatment cont
Propranolol has the additional effects or blocking
perpheral conversion of T4-T3
Avoid Salicylates because it may displace T4 from
TBG
If the patient continues to deteriorate despite
appropriate therapy circulating thyroid hormone may
be removed by plasma transfusion, plasmapheresis,
charchoal plasmaperfusion
Remember you must not administer iodine until
the synthetic pathway has been blocked
 Thyroid Storm
Disposition
Admit to the ICU
Hypothyroidism and
Myxedeam Coma
Tintinalli Chapter 215
12/15/05

Prepared by Trent W. Smith

Lecture by Dr. Klien MD
 Hypothyroidism
Occurs when there is insufficient hormone
production or secretion
Occurs more frequently in women (0.6 to 5.9 %)
The most common etiologies are
Primary thyroid failure due to autoimmune diseases
(Hashimoto thyroiditis is the most common)
Idiopathic causes
Ablative therapy
Iodine deficiency
May be transient
Pathophysiology is unclear but may be viral in nature
 Hypothyroidism
Etiologies of Hypothyroidism
Primary
Autoimmune etiologies
Hashimotos is the most common
Idopathic
Post ablation (surgical, radioiodine)
Post external radiation
Thryoiditis (subacute, silent, postpartum)
Postpartum thyroiditis occurs within 3-6 months and occurs in
2- 16 % of women
Self limited etiologies, often prededed by hyperthroid phase
Infiltrative disease (lymphoma, sarcoid, amyloidosis,
Tuberculosis
Congenital
 Hypothyroidism
Etiologies of Hypothyroidism
Post Partum
Occurs 3-6 months post partum and occurs in 2-16% of
women
Secondary (pituitary)
Neoplasm
Infiltrative Dz.
Hemorrhage
Tertiary (hypothalamic)
Neoplasm
Infiltrative Dz.
 Hypothyroidism
Etiologies of Hypothyroidism
Drugs
Amiodarone
Occurs in 1-32% of patients
Most likely due to the large amount of iodine released in the
metabolism of the drug which inhibits thyroid hormone
synthesis, release, and conversion of T4 to T3
Lithium
Acts similarly to iodine and inhibit thyroid hormone release
Iodine (in patients with pre-existing autoimmune disease)
Antithyroid medication
 Hypothyroidism
Clinical Features
The typical symptoms of hypothyroidism
include fatigue, weakness, cold intolerance,
constipation, weight gain, and deepening of
voice.
Cautaneous signs include dry, scaly, yellow
skin, non-pitting, waxy edema of the face and
extremities (myxedema): and thinning
eyebrows
 Hypothyroidism
Clinical Features cont.
Cardiac findings include bradycardia,
enlarged heart, and low-voltage
electrocardiogram
Paresthesia, ataxia, and prolongation or
DTRs are characteristic neurologic findings
See table below for more complete list
 Hypothyroidism
Symptoms and Signs or Hypothyroidism (table 216-2)
Symptoms Signs
Fatigue Hoarseness
Weight Gain Hypothermia
Cold intolerance Periobital puffiness
Depression Delayed relaxation of ankle
jerks
Menstrual irregularities Loss of outer third of eyebrow
Constipation Cool, rough, dry skin
Joint Pain Nonpitting edema
Muscle cramps Bracycardia
Infertility Peripheral Neuropathy
 Hypothyroidism
Treatment
Most patient with uncomplicated symptomatic
Hypothyroidism may be referred to the
primary physician for further evaluation and
initiation of treatment
If hypothyroidism is due to a secondary
etiology initiation of thyroid hormone therapy
may exacerbate preexisting adrenal
insufficiency
 Myxedema
Myxedema is a rare life threatening
decompensation of hypothyroidism
Usually in individuals with long-standing
hypothyroidism
Most often seen in the winter months
More common in elderly women with
underdiagnosed or undertreated
hypothyroidism
 Myxedema
Precipitating events include
Infection
CHF
Trauma
CVA
Exposure to cold
Drugs
Sedatives
Lithium
Amiodarone
 Myxedema
In addition to the clinical features of hypothyroidism
patients may present with
Hypothermia
Altered metal status
Coma, delusions, and psychosis (myxedema maddness)
Hyponatremia
Dilutional secondary to decreased free-water clearance
Hypoglycemia
Secondary to impaired gluconeogenesis
Hypotension
Bradycardia
Respiratory Failure
Secondary to decreased strength of respiratory muscle
Hypercapnia and hypoxia is common
 Myxedema
Diagnosis
Must have high clinical suspicion
Commonly has Hx. Of hypothyroidism
Delcine in function is usually insidious in
onset
 Myxedema
Diagnosis cont
Laboratory evaluation may reveal
Anemia
Hyponatremia
Hypoglycemia
Transaminases
CPK
LDH
Po2 and PCo2 on ABGs
 Myxedema
Diagnosis cont.
EKG may reveal
Sinus Bradycardia
Prolonged QT interval
Low voltage
Flattened or inverted T waves
 Myxedema
Treatment (see table 216-5 below)
No prospective studies on optimal therapy have been
done thus treatment recommendations are not
uniform
Airway stabilization with adequate oxygenation and
ventilation or vital
Cardiovascular status must be monitored closely
Hypothermic patients should be gradually rewarmed
with gentle passive external rewarming
Hypotension from reversal of hypothermic vasoconstriction
should be avoided
 Myxedema
Treatment cont.
Hyponatremia typically responds to fluid
restrictions. Severe cases may require
hypertonic saline with lasixs
Vasopressors are usually ineffective and
should only be used in severe hypotension
Lovothyroxine 300-500 mcg slow IVP
followed by 50-100 mcg daily
 Myxedema
Treatment cont.
L-triiodothyronine 25 mcg IV or orally q 8 h is a
alternative
This dose should be halved in patients with cardiovascular
disease
Hydrocortisone 100 mg IV q 8 hours should
be given
Send baseline cortisol level to lab if possible
Precipitating causes should be sought and
treated
 Myxedema
Treatment of Myxedema Coma (table 216-5)
Recognition
Supportive therapy including ventilatory support
Thyroid replacement
Lovothyroxine 300-500 mcg slow IVP followed by 50-100 mcg daily or
T3 25 mcg IV or PO q 8 hrs
Glucocorticoid
Hydrocortisone: 100 mg IV q8h
Hypothermia
Prevent additional loss
Passive external rewarming
Electrolyte correction
Gentle fluid restriction for dilutional hyponatremia
Hypertonic saline for severe hyponatremia
Hypoglycemia
Dextrose-containing IV fluids
Monitoring
Aggressive treatment of presipitating causes
Admit patient to a monitored setting
 Myxedema
Disposition
Admit to appropiately monitored bed
 Questions
1. Hyperthyroidism is Characterized by
which of the following
A. Fatigue
B. Palpitations
C. Weight Loss
D. Heat intolerance
E. All the above
 2. The most common etiology of
hyperthyroidism is
A. Toxic Multinodular
B. Graves
C. Toxic Nodular
D. Amiodarone induces
 3. Typical Feature of Hyperthyroidism
include
A. Fatigue
B. Weakness
C. Constipation
E. Cold Intolerance
F. All the above
 4. T or F Hyperthyroidism is more common
in women
5. T or F Hypothyroidism is more common
in women
6. T or F Mild hyperthyroidism may be
treated with B-blockers

Answers 1. E 2. B 3. F 4.T 5.T 6.T