Thyroid Emergencies

Muhammad Adib Thaqif Bin Mazlan

Hospital Dungun
 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

• Active Transport of Iodide into the follicular cell

• Thyroglobulin formation
• Exocytosis of thyroglobulin
• Iodination of the thyroglobulin
• Coupling of MIT and DIT
• Endocytosis of iodinated thyroglobulin
Hypothyroid and Hyperthyroid
Lab Investigations
 Goals of Discussion
• Hyperthryoidism
Thyroid Storm

• Hypothryoidism
Myxedema Coma
 Hypothyroidism
Systems Clinical Symptoms
Nervous System Forgetfulness and mental slowing
Paresthesias
Carpal tunnel
Ataxia and decreased hearing
Cardiovascular Bradycardia
Decreased cardiac output
Pericardial effusion
Dependent edema
Gastrointestinal Constipation
Achlorhydria with pernicious anemia
Ascitic fluid with high protein
Renal Reduced excretion of water load
Musculoskeletal Arthralgia
Joint effusions
Muscle cramps
 Hypothyroidism
Symptoms
Systems Clinical Symptoms
Skin and hair Loss of lateral eye brows
Dry, cool skin
Facial features
Coarse and puff
Metabolism Hypothermia
Intolerance to cold
Increased cholesterol and triglyceride
Weight gain
Pulmonary Responses to hypoxia and
hypercapnia are decreased
Pleural effusions high protein
Reproductive system Menorrhagia from anovulatory cycles
Hyperprolactinemia
No inhibition of thyroid hormone
 Myxedema Coma
• Extreme complications in which patients exhibit multiple organ
abnormalities and progressive mental deterioration
• Myxedema is also used to describe the dermatologic changes
occured
• Even with early detection and appropriate treatment, mortality
ranges from 30-60%
• Altered mental status
• Decreased orientation
• Increased lethargy
• Confusion/psychosis
 Causes Or Precipitating Illness
• Precipitating illness or event
– Infections
– Trauma
– Surgery
– Stroke
– Metabolism
• Hypoglycemia
• Hypothermia
• CO2 narcosis
– Medications
• Diuretics
• Sedatives
• Drug overdose
 Investigations
• If the condition is suspected, treatment should be started immediately without waiting
for the results.
• Other investigations
– Serum osmolality
– Serum creatinine
– Full blood Count
– Serum cortisol
– Radiograph (Signs of failure)
– Electrocardiograph (Sinus bradycardia, low amplitude QRS complexes, prolonged QT interval, flattened or
inverted T waves
 Managements
• Body temperature support
– Poikilothermic
• Respiratory support
– Intubation may be needed
• 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 or Dexamethasone 2-4mg every 12
hours
 Thyroid hormone therapy
• IV Levothyroxine 200-400 ug Stat, Then
• IV Levothyroxine 50-100 ug QID
• 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 TDS
• 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
• IV 100 mcg then 140 mcg PO
Hyperthyroidism
 Hyperthyroid
Systems Clinical Symptoms
Nervous System Nervousness and Anxiety
Decreased Sleep and Concentration
Irritability
Cardiovascular Tachycardia
Atrial Fibbrilation
Increased cardia output
Gastrointestinal Weight loss
Increased hunger
Uincreased stool frequency
Musculoskeletal Weakness and Fatigue
Skin and hair Diaphoresis
Metabolism Heat Intolerance
Goitre
Opthalmology Exophtalmus
Reproductive system Change in menstural cycle
 Thyroid Storm

• Decompensated state of thyroid hormone-induced,

severe hypermetabolism involving multiple
systems
– Clinically relates to severly exaggerated effects of thyroid
hormones
• Hyperthermia
• CNS effects
– Delirium, psychosis, coma, seizure
• Cardiac
– Tachycardia, Heart failure, Arrythmia
• GI/Liver dysfunction
– Jaundice, Diarrhea, nausea, vomiting and abdominal pain
Precipitating Factors
Burch-Wartofsky Criteria
• Common laboratory findings
• Low (or non-detectable) TSH and elevated T3/T4
• Hyperkalemia + hyponatremia (in concomitant
adrenal insufficiency)
• Anemia
• Thrombocytopenia
• Low serum creatinine
• Hypercalcemia
 Management
• Supportive care
• Inhibition of peripheral adrenergic effects
• Inhibition of new hormone synthesis
• Inhibition of thyroid hormone release
• Preventing peripheral conversion of T4 to T3
• Preventing free thyroid hormone reabsorption
• Treating the precipitant
• Definitive care
 Management
• ICU Setting preparations
• Supportive managements
– Hyperthermia
• Cooling blankets
• Acetaminophen
• Avoid aspirin
– Can displace thyroid hormones from binding proteins
– Fluids 3-5 liters per day
– Include glucose and thiamine
– Avoid congestive heart failure
• Diuretics
• Digoxin
– Requires higher doses in thyroid storm
 Medications
• Antiadrenergic drugs
– Beta blockers
• Use of IV Short-acting beta-1 blockers allows quick dose titration with
minimization of side effects
– Oral Propanolol 60mg – 80mg every 4-6hours
• Thionamides
– High dose of PTU is preferred over methimazole because of rapid onset and
capacity to inhibit peripheral conversion
• 1000mg stat, then 200mg - 250mg every 4 hours orally
• Iodine compounds
– Lugol iodine or potassium iodide to block release of thyroid hormones (at least 1
hour after antithyroid drug therapy
• 8 Drops every 6 hours
• Glucocorticoids
– To decrease peripheral conversion of T4 to T3
• IV Hydrocortisone 100mg IV or IV Dexamethasone 1-2mg every 6-8 hours