215 hyperthyroid & thyroid storm
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Ch 215
Hyperthyroidism & Thyroid
Storm
Carrie L. Lotenero, DO
September 27
th
, 2007
Causes of Thyrotoxicosis
•
Primary
hyperthyroidism
–
Graves dz
–
Toxic multinodular
goiter
–
Toxic nodular
goiter
–
Iodine intake
•
Central
hyperthyroidism
–
Pituitary adenoma
Causes of Thyrotoxicosis
•
Thyroiditis
–
Subacute painful
(de Quervain)
–
Silent subacute
–
Postpartum
–
Radiation
thyroiditis
•
Non-thyroidal dz
–
Ectopic thyroid
tissue
–
Metastatic thyroid
CA
•
Drug-induced
–
Lithium
–
Iodine
–
Amiodarone
–
Excessive TH
ingestion
Sx of hyperthyroidism
•
Weakness
•
Fatigue
•
Heat intolerance
•
Nervousness
•
Sweating
•
Tremor
•
Palpitation
•
↑ appetite
•
Weight loss
•
Hyperdefecation
•
Dyspnea
•
Menstrual
abnormalities
Signs of Hyperthyroidism
•
Goiter
•
Thyroid bruit
•
Hyperkinesis
•
Ophthalmopathy
•
Lid retraction/stare
•
Lid lag
•
Tremor
•
Warm, moist skin
•
Muscle weakness
•
Hyperreflxia
•
Tachycardia/arrhyt
hmia
•
↑ SBP
•
Widened pulse
pressure
Thyroid Storm: Precipitants
•
Infection
•
Trauma
•
DKA
•
AMI
•
CVA
•
PE
•
General surgery
•
w/d thyroid meds
•
Iodine
•
Palpation of
thyroid gland
•
Ingestion of TH
•
Unknown in 20-
25% of cases
Hamburger
Thyrotoxicosis
•
“gullet trimming”
•
Hedberg and colleagues (1987) described
an outbreak of thyrotoxicosis in Minnesota
and South Dakota
–
121 cases identified in 9 counties
–
highest incidence in
county with offending
slaughter plant
DDX thyroid storm
•
Sepsis
•
Sympathomimetic
ingestion
–
cocaine,
amphetamine
•
Heat stroke
•
DTs
•
Malignant
hyperthermia/neur
oleptic syndrome
•
Hypothalamic
stroke
•
Pheo
•
Med w/d
Thyroid Storm: si/sx
•
Fever
•
Tachycardia
•
Arrhythmia
•
CHF
•
CNS
–
Agitation
–
Confusion
–
Delirium
–
Stupor
–
Coma
–
Seizure
TX thyroid storm
•
#1 Decrease synthesis
–
PTU: 600-1000mg PO, followed by 200-
250mg Q4h
–
Methimazole: 40mg PO, then
25mg PO Q6h
TX thyroid storm
•
#2 Prevent release
–
Iodine:
•
Iapanoic acid (Telepaque): 1g IV Q8h x
24h, then 500mg IV bid, or
•
Potassium Iodide (SSKI): 5gtts PO Q6h,
or
•
Lugol solution: 8-10gtts PO Q6h
–
Lithium carbonate: 800-1200mg PO QD
TX thyroid storm
•
Prevent peripheral effects
–
ß- blockade:
•
Propanolol: titrate 1-2mg IV Q5min prn
(may need 240-480mg PO QD), or
•
Esmolol: 500µg/kg IV bolus, then 50-200
µg/kg/min
–
Guanethidine: 30-40mg PO Q6h
–
Reserpine: 2.5-5mg IM Q4-6h
TX thyroid storm
•
Others
–
Corticosteroids:
•
Hydrocortisone 100mg IV Q8h, or
•
Dexamethasone 2mg IV Q6h
–
Antipyretics: cooling blanket, Tylenol 650mg
PO q4h
•
Avoid salicylates!
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