Diferencia entre revisiones de «Thyroid storm»

m (Rossdonaldson1 moved page Thyroid Storm to Thyroid storm)
Línea 154: Línea 154:
**[[Blood culture]]
**[[Blood culture]]


== Treatment ==
== Treatment<ref>American Thyroid Association Treatment Recomendations http://www.thyroid.org/thyroid-guidelines/hyperthyroidism/resultsh/</ref>==
Identify precipitant (ie med noncompliance, DKA, infection)
===Supportive care===
#'''[[Fever]]'''
##Cooling measures (ice packs & cooling blankets), acetaminophen (avoid aspirin)
#'''[[Dehydration]]/[[hypoglycemia]]'''
##D5NS (most pts have depleted glycogen stores)
#Cardiac decompensation ([[CHF]], [[A-fib]])
##Rate control, inotropes, diuretics as needed
===Decrease Peripheral Hormone Conversion===
''can use PO or IV Propranolol''
#'''Propranolol''' PO 60-80 q4hr (if pt can tolerate PO)
#'''Propranolol''' IV 1-2mg over 10 min; if tolerates then 1-3mg boluses q3hr OR
#*Contraindications are same as for other medical conditions (e.g. [[CHF]])
===Block new hormone synthesis===
''PTU is prefered over methimazole because it will also bock T4->T3 conversion
#PTU 600-1000 mg PO or PR followed by 200-250mg q4hr
#*Note black box warning of hepatotoxicity so check LFTs prior
#*Avoid in patients with significant liver disease and use Methimazole instead
#'''Methimazole''' 20-25mg q4hr
#*Longer acting than PTU
===Other Therapies===
#Esmolol 250-500mcg/kg loading dose, then 50-100mcg/kg/min
#*B1 selective so can be used in pt with active CHF, asthma, etc.
#'''Potassium iodide (SSKI)'''
#*Give 1hr after PTU to prevent increased hormone production (Jod-Basedow effect)
#*Block hormone release: (Wolff-Chaikoff effect) only after hormone synthesis is inhibited. Iodine concentration leads to transient decrease of T3/T4
#*5 drops (0.25 mL or 250 mg) orally every 6 hours
#*Avoid potassium iodide if patient is on amiodarone
#*Can substitute radiocontrast dyes (Iopanoic acid, ipodate and iopanoate) or oral lugol solution
#Lithium carbonate<ref>Carroll R, Matfin G. Endocrine and metabolic emergencies: thyroid storm. Ther Adv Endocrinol Metab. 2010 Jun; 1(3): 139–145. [http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3475282/ Full Text]
#300mg q6hrConsider if iodine allergic


#Supportive care
===Adrenal Insufficiency Treatment==
##[[Fever]]
''Often there may be associated adrenal insufficiency (also blocks T4>T3)''
###Cooling measures (ice packs & cooling blankets), acetaminophen (avoid aspirin)
#'''Hydrocortisone''' 100-300mg IV bolus, followed by 100mg q8hr OR Dexamethasone 2mg IV q6hr
##Dehydration/[[hypoglycemia]]
###D5NS (most pts have depleted glycogen stores)
##Cardiac decompensation ([[CHF]], [[A-fib]])
###Rate control, inotropes, diuretics as needed
#Block beta-adrenergic tone and peripheral T4>T3 conversion
##Contraindications are same as for other medical conditions (e.g. CHF)
##Propranolol PO 60-80 q4hr (if pt can tolerate PO) OR
##Propranolol IV 1-2mg over 10 min; if tolerates then 1-3mg boluses q3hr OR
##Esmolol 250-500mcg/kg loading dose, then 50-100mcg/kg/min - B1 selective so can be used in pt with active CHF, asthma, etc.
#Block new hormone synthesis
##PTU 600-1000 mg PO or PR followed by 200-250mg q4hr
###Preferred to methimazole b/c also blocks T4&gt;T3 conversion
###Note black box warning of hepatotoxicity
##Methimazole 20-25mg q4hr
###Longer acting than PTU
#Block hormone release: Only after hormone synthesis is inhibited
##Wolff-Chaikoff effect: incr iodine concentration leads to transient decrease of T3/T4
###Likely due to suppression of already-formed thyroid hormone release
##Potassium iodide (SSKI)
###Give 1hr after PTU to prevent increased hormone production (Jod-Basedow effect)
###1st line
###5 gtt q6hr
####Avoid potassium iodide if patient is on amiodarone
####Can substitute radiocontrast dyes (Iopanoic acid, ipodate and iopanoate) or oral lugol solution
##Lithium
###Consider if iodine allergic
###300mg q6hr
#Treat possible adrenal insufficiency (also blocks T4>T3)  
##Hydrocortisone 100-300mg IV bolus, followed by 100mg q8hr OR Dexamethasone 2mg IV q6hr
#Plasmapheresis
#Identify precipitant (ie med noncompliance, DKA, infection)


==Disposition==
==Disposition==

Revisión del 04:45 8 feb 2015

Background

  • Mortality
    • Without treatment: 80-100%
    • With treatment: 15-50%

Precipitants

  1. Infection
  2. Trauma
  3. Surgery
  4. DKA
  5. Withdrawal of thyroid medication
  6. Iodine administration
  7. MI
  8. CVA
  9. PE

Diagnosis

  1. Classic Triad:
    1. Hyperthermia
    2. Tachycardia
    3. AMS
      1. Agitation, confusion, delirium stupor, coma, seizure
  2. May also have:
    1. CHF
    2. Palpitations
    3. Dyspnea
    4. Increased pulse pressure
    5. A-fib

Burch & Wartofsky Diagnostic Criteria

I. Thermoregulatory dysfunction (Temperature)

Temp Points
99-99.9 5
100-100.9 10
101-101.9 15
102-102.9 20
103-103.9 25
104.0 30


II. Central nervous system effects

Mild (Agitation) 10pts
Moderate (delirium, psychosis, extreme lethargy) 20pts
Severe (seizure, coma) 30pts

III. Gastrointestinal-hepatic dysfunction

Moderate (diarrhea, n/v, abd pain) 10pts
Severe (unexplained jaundice) 20pts

IV. Cardiovascular dysfunction (tachycardia)

99-109 5pts
110-119 10pts
120-129 15pts
130-139 20pts
140 25pts

V. Congestive Heart Failure

Mild (pedal edema) 5pts
Moderate (bibasilar rales) 10pts
Severe (pulm edema, A. fib) 15pts

VI. Precipitant history

Negative 0pts
Positive 10pts

Scoring

  • >45 = Highly suggestive of thyroid storm
  • 25-44 = Suggestive of impending storm
  • <25 = Unlikely to represent storm

Differential Diagnosis

Work-Up

  • Chemistry
  • CBC
  • TSH/Free T3/T4
  • Cortisol level (rule-out concurrent adrenal insufficiency)
  • ECG
  • Rule-out infection:

Treatment[1]

Identify precipitant (ie med noncompliance, DKA, infection)

Supportive care

  1. Fever
    1. Cooling measures (ice packs & cooling blankets), acetaminophen (avoid aspirin)
  2. Dehydration/hypoglycemia
    1. D5NS (most pts have depleted glycogen stores)
  3. Cardiac decompensation (CHF, A-fib)
    1. Rate control, inotropes, diuretics as needed

Decrease Peripheral Hormone Conversion

can use PO or IV Propranolol

  1. Propranolol PO 60-80 q4hr (if pt can tolerate PO)
  2. Propranolol IV 1-2mg over 10 min; if tolerates then 1-3mg boluses q3hr OR
    • Contraindications are same as for other medical conditions (e.g. CHF)

Block new hormone synthesis

PTU is prefered over methimazole because it will also bock T4->T3 conversion

  1. PTU 600-1000 mg PO or PR followed by 200-250mg q4hr
    • Note black box warning of hepatotoxicity so check LFTs prior
    • Avoid in patients with significant liver disease and use Methimazole instead
  2. Methimazole 20-25mg q4hr
    • Longer acting than PTU

Other Therapies

  1. Esmolol 250-500mcg/kg loading dose, then 50-100mcg/kg/min
    • B1 selective so can be used in pt with active CHF, asthma, etc.
  2. Potassium iodide (SSKI)
    • Give 1hr after PTU to prevent increased hormone production (Jod-Basedow effect)
    • Block hormone release: (Wolff-Chaikoff effect) only after hormone synthesis is inhibited. Iodine concentration leads to transient decrease of T3/T4
    • 5 drops (0.25 mL or 250 mg) orally every 6 hours
    • Avoid potassium iodide if patient is on amiodarone
    • Can substitute radiocontrast dyes (Iopanoic acid, ipodate and iopanoate) or oral lugol solution
  3. Lithium carbonate<ref>Carroll R, Matfin G. Endocrine and metabolic emergencies: thyroid storm. Ther Adv Endocrinol Metab. 2010 Jun; 1(3): 139–145. Full Text
  4. 300mg q6hrConsider if iodine allergic

=Adrenal Insufficiency Treatment

Often there may be associated adrenal insufficiency (also blocks T4>T3)

  1. Hydrocortisone 100-300mg IV bolus, followed by 100mg q8hr OR Dexamethasone 2mg IV q6hr

Disposition

  • Admission to ICU

See Also

Sources

  • Tintinalli
  • UpToDate
  • Burch, HB, Wartofsky, L, Endocrinol Metab Clin North Am 1993; 22:263
  • Rosen
  1. ↑ American Thyroid Association Treatment Recomendations http://www.thyroid.org/thyroid-guidelines/hyperthyroidism/resultsh/
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