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    Thyroid Storm

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    togi_siahaan
    1) Thyroid storm is an acute, life-threatening exacerbation of hyperthyroidism characterized by extreme hypermetabolism. It occurs in less than 10% of hospitalized thyrotoxic patients and has a mortality rate of 20-30%. 2) Common causes include Graves' disease, multinodular goiter, or hyperthyroidism aggravated by iodine exposure. Precipitating events are often infection, discontinuing antithyroid medication, or surgery. 3) Diagnosis is based on symptoms of extreme heat intolerance, tachycardia, delirium and a Burch-Wartofsky score of over 45. Treatment focuses on inhibiting thyroid hormone synthesis, blocking

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    Thyroid Storm

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    togi_siahaan
    174 views23 pages
    1) Thyroid storm is an acute, life-threatening exacerbation of hyperthyroidism characterized by extreme hypermetabolism. It occurs in less than 10% of hospitalized thyrotoxic patients and has a mortality rate of 20-30%. 2) Common causes include Graves' disease, multinodular goiter, or hyperthyroidism aggravated by iodine exposure. Precipitating events are often infection, discontinuing antithyroid medication, or surgery. 3) Diagnosis is based on symptoms of extreme heat intolerance, tachycardia, delirium and a Burch-Wartofsky score of over 45. Treatment focuses on inhibiting thyroid hormone synthesis, blocking

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    1) Thyroid storm is an acute, life-threatening exacerbation of hyperthyroidism characterized by extreme hypermetabolism. It occurs in less than 10% of hospitalized thyrotoxic patients and has a mortality rate of 20-30%. 2) Common causes include Graves' disease, multinodular goiter, or hyperthyroidism aggravated by iodine exposure. Precipitating events are often infection, discontinuing antithyroid medication, or surgery. 3) Diagnosis is based on symptoms of extreme heat intolerance, tachycardia, delirium and a Burch-Wartofsky score of over 45. Treatment focuses on inhibiting thyroid hormone synthesis, blocking

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    174 views23 pages

    Thyroid Storm

    Uploaded by

    togi_siahaan
    1) Thyroid storm is an acute, life-threatening exacerbation of hyperthyroidism characterized by extreme hypermetabolism. It occurs in less than 10% of hospitalized thyrotoxic patients and has a mortality rate of 20-30%. 2) Common causes include Graves' disease, multinodular goiter, or hyperthyroidism aggravated by iodine exposure. Precipitating events are often infection, discontinuing antithyroid medication, or surgery. 3) Diagnosis is based on symptoms of extreme heat intolerance, tachycardia, delirium and a Burch-Wartofsky score of over 45. Treatment focuses on inhibiting thyroid hormone synthesis, blocking

    Copyright:

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    Thyroid Storm

    Thyrotoxicosis and Thyroid Storm Harrison's Principles of Internal Medicine Perioperative management of the thyrotoxic patient

    Bindu Nayak, MD, Kenneth Burman, MD, Endocrinol Metab Clin N Am 35(2006) 663-686

    Roy W. Langley, MD, Henry B. Burch, MD, Endocrinol Metab Clin N Am 32 (2003) 519534

    Intern P.D.Chen

    Thyroid Storm

    Exacerbation of hyperthyroidism Acute, life-threatening, hypermetabolic state Thyroid storm may be the initial presentation of thyrotoxicosis Less than 10% of hospitalized thyrotoxicosis Mortality: 20-30%

    Intern P.D.Chen

    Thyroid Storm underlying cause


    Graves disease Solitary, multinodular goitor Hypersecretory thyroid carcinoma Axis related tumor Hyperthyroidism aggravated by iodine exposure (radiocontrast, Amiodarone)

    Intern P.D.Chen

    Thyroid Storm precipitating event


    Systemic insults Discontinuation of antithyroid drug Pseudoephedrine, salicylate use Most common: infection

    Intern P.D.Chen

    Thyroid Storm pathophysiology I

    Patients with thyroid storm have relatively higher levels of free thyroid hormones(THs) than patients with uncomplicated thyrotoxicosis, even though total TH levels may not be increased.

    Adrenergic receptor activation is a hypothesis. Sympathetic nerves innervate the thyroid gland, and catecholamines stimulate TH synthesis. In turn, increased THs increase the density of betaadrenergic receptors, thereby enhancing the effect of catecholamines.
    Intern P.D.Chen

    Thyroid Storm pathophysiology II

    Another theory suggests a rapid rise of hormone levels as the pathogenic source. A drop in binding protein levels, which may occur postoperatively, might cause a sudden rise in free hormone levels. In addition, hormone levels may rise rapidly when the gland is manipulated during surgery, during vigorous palpation during examination, or from damaged follicles following RAI therapy. Other proposed theories include alterations in tissue tolerance to THs, the presence of a unique catecholaminelike substance in thyrotoxicosis, and a direct sympathomimetic effect of TH as a result of its structural similarity to catecholamines.
    Intern P.D.Chen

    Thyroid Storm presentation I

    Heat intolerance and diaphoresis are common in simple thyrotoxicosis -> hyperpyrexia in thyroid storm. Extremely high metabolism increases oxygen and energy consumption. Cardiac findings in thyrotoxicosis -> accelerated tachycardia, hypertension, high-output cardiac failure, and a propensity to develop cardiac arrhythmias.

    Intern P.D.Chen

    Thyroid Storm presentation II

    irritability and restlessness in thyrotoxicosis -> severe agitation, delirium, seizures, and coma. mild elevations of transaminases and simple enhancement of intestinal transport in thyrotoxicosis -> diarrhea, vomiting, jaundice, and abdominal pain

    Intern P.D.Chen

    Thyroid Storm - diagnosis

    37.2 37.7C

    40C

    A score of 45 or more is highly suggestive of thyroid storm; a score of 25 to 44 supports the diagnosis; and a score below 25 makes thyroid storm unlikely.
    Adapted from Burch, HB, Wartofsky, L, Endocrinol Metab Clin North Am 1993; 22:263.

    Intern P.D.Chen

    Thyroid Storm - prognosis

    The mortality rate due to cardiac failure, arrhythmia, or hyperthermia is as high as 30%, even with treatment.

    Thyrotoxic crisis is usually precipitated by acute illness, surgery (especially on the thyroid), or radioiodine treatment of a patient with partially treated or untreated hyperthyroidism.

    10

    Intern P.D.Chen

    Thyroid Storm treatment I

    Medications to halt the synthesis, release, and peripheral effects of thyroid hormone. Controlling adrenergic symptoms and systemic decompensation with supportive therapy

    11

    Intern P.D.Chen

    Thyroid Storm treatment II


    Inhibition of new hormone
    Thionamide (PTU, MMI)

    Removal of excess circulating hormone


    Plamapheresis Charcoal plasmaperfusion

    Antiadrenergic agents
    Reserpine Guanethidine

    Inhibition of T4-to-T3 conversion

    Inhibition of hormone release

    Iodine Potassium iodide, Lugols solution, iopanoic acid Lithium carbonate

    PTU Corticosteroids Iopanoic acid, amiodarone Beta-adrenergic blockade Propranolol

    12

    Intern P.D.Chen

    Thyroid Storm treatment III

    Thionamides interfere with thyroperoxidasecatalyzed coupling, and inhibitory effect on thyroid follicular cell function and growth Thiouracil (propylthiouracil) v.s. imidazoles (methimazole, carbimazole) SE: abnormal taste, pruritus, urticaria, fever, arthralgia; agranulocytosis, hepatotoxicity, vasculitis

    13

    Intern P.D.Chen

    Thyroid Storm treatment IV

    Thionamides interfere with thyroperoxidasecatalyzed coupling, and inhibitory effect on thyroid follicular cell function and growth Thiouracil (propylthiouracil) v.s. imidazoles (methimazole, carbimazole) SE: abnormal taste, pruritus, urticaria, fever, arthralgia; agranulocytosis, hepatotoxicity, vasculitis

    14

    Intern P.D.Chen

    Thyroid Storm treatment V

    Large doses of propylthiouracil (600mg loading dose and 200 to 300 mg every 6 h) orally or per rectum; stable iodide is given to block thyroid hormone synthesis via the Wolff-Chaikoff effect : saturated solution of potassium iodide (5 drops SSKI every 6 h), or ipodate or iopanoic acid (0.5 mg every 12 h), may be given orally. (Sodium iodide, 0.25 g intravenously
    One hour after the first dose of propylthiouracil, every 6 h is an alternative but is not generally available.)
    Intern P.D.Chen

    15

    Thyroid Storm treatment VI

    Propranolol should also be given to reduce tachycardia and other adrenergic manifestations
    (40 to 60 mg orally every 4 h; or 2 mg intravenously every 4 h).

    Additional therapeutic measures include glucocorticoids (e.g., dexamethasone, 2 mg every 6 h), antibiotics if infection is present, cooling, oxygen, and intravenous fluids.

    16

    Intern P.D.Chen

    Thyroid Storm operation consideration

    8%-20% mortality in the past

    1% with pre-op inorganic iodine


    E.B. Astwood, May 8, 1943: Dr. Plummer Treatment of hyperthyroidism with thiourea and thiouracil. Physician, scientist, architect and engineer, Dr. Henry Plummer has rightly been called "a diversified genius."

    17

    Intern P.D.Chen

    Thyroid Storm operation consideration


    Absolute indications
    Failed medical therapy Severe reaction to antithyroidal drugs and not a candidate for radioablation therapy Persistent thyrotoxicosis despite maximum antithyroidal drug therapy or repeated radioablation treatments Underlying thyroid cancer Suspicious or malignant nodules on FNA

    Relative Indications
    Symptomatic goiters Pregnancy Severe Graves ophthalmopathy Refractory thyroiditis Amiodarone related Nonremitting subacute thyroiditis Toxic adenoma Rapid control of symptoms required Aversion to antithyroidal drugs and radioablation therapy
    Intern P.D.Chen

    18

    Thyroid Storm pre-operation consideration

    A combination of targets in the thyroid hormone synthetic, secretory and peripheral action pathways. Concurrent treatment to reverse any decompensation of normal homeostatic mechanisms
    Intern P.D.Chen

    19

    Thyroid Storm pre-operation rapid preparation


    Beta-adrenergic blockade Thionamide Oral cholecystographic agents Cortiosteroid Continue after operation?

    20

    Intern P.D.Chen

    Thyroid Storm post-operation consideration

    Keep regimen after resolution of thyrotoxicity Monitor thyroid hormones To render the patient as close as possible to clinical and biochemical euthyroidism

    21

    Intern P.D.Chen

    Thyroid Storm - Take home message

    High fever

    A score of 45 or more is highly suggestive of thyroid storm Conscious change

    22

    Intern P.D.Chen

    Thanks you for attention

    Rembrandt van Rijn1606 ~ 1669

    23

    Intern P.D.Chen

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