Diferencia entre revisiones de «Thyroid storm»

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== Background ==
== Background ==
*Mortality
 
**Without treatment: 80-100%
*Mortality  
**Without treatment: 80-100%  
**With treatment: 15-50%
**With treatment: 15-50%


===Precipitants===
=== Precipitants ===
#Infection
 
#Trauma
#Infection  
#Surgery
#Trauma  
#DKA
#Surgery  
#Withdrawal of thyroid medication
#DKA  
#Iodine administration
#Withdrawal of thyroid medication  
#MI
#Iodine administration  
#CVA
#MI  
#CVA  
#PE
#PE


==Diagnosis==
== Diagnosis ==
#Classic Triad:
 
##Hyperthermia
#Classic Triad:  
##Tachycardia
##Hyperthermia  
##AMS
##Tachycardia  
###Agitation, confusion, delirium stupor, coma, seizure
##AMS  
#May also have:
###Agitation, confusion, delirium stupor, coma, seizure  
##CHF
#May also have:  
##Palpitations
##CHF  
##Dyspnea
##Palpitations  
##Increased pulse pressure
##Dyspnea  
##Increased pulse pressure  
##A-fib
##A-fib


=== Burch & Wartofsky Diagnostic Criteria ===
=== Burch & Wartofsky Diagnostic Criteria ===


'''I. Thermoregulatory dysfunction (Temperature)'''
'''I. Thermoregulatory dysfunction (Temperature)'''  


{| border="1"
{| width="300" border="1" cellpadding="1" cellspacing="1"
|-
| Temp
| Points
|-
|-
| 99-99.9
| 99-99.9
Línea 52: Línea 58:
| 30
| 30
|}
|}


'''II. Central nervous system effects'''
'''II. Central nervous system effects'''
Línea 57: Línea 64:
{| border="1"
{| border="1"
|-
|-
| Mild (Agitation)
| Mild (Agitation)  
| 10
| 10pts
|-
|-
| Moderate (delirium, psychosis, extreme lethargy)
| Moderate (delirium, psychosis, extreme lethargy)  
| 20
| 20pts
|-
|-
| Severe (seizure, coma)
| Severe (seizure, coma)  
| 30
| 30pts
|}
|}


'''III. Gastrointestinal-hepatic dysfunction'''
'''III. Gastrointestinal-hepatic dysfunction'''  


{| border="1"
{| border="1"
|-
|-
| Moderate (diarrhea, n/v, abd pain)
| Moderate (diarrhea, n/v, abd pain)  
| 10
| 10pts
|-
|-
| Severe (unexplained jaundice)
| Severe (unexplained jaundice)  
| 20
| 20pts
|}
|}


'''IV. Cardiovascular dysfunction (tachycardia)'''
'''IV. Cardiovascular dysfunction (tachycardia)'''  


{| border="1"
{| border="1"
|-
|-
| 99-109
| 99-109  
| 5
| 5pts
|-
|-
| 110-119
| 110-119  
| 10
| 10pts
|-
|-
| 120-129
| 120-129  
| 15
| 15pts
|-
|-
| 130-139
| 130-139  
| 20
| 20pts
|-
|-
| 140
| 140  
| 25
| 25pts
|}
|}


'''V. Congestive heart failure'''
'''V. Congestive heart failure'''  


{| border="1"
{| border="1"
|-
|-
| Mild (pedal edema)
| Mild (pedal edema)  
| 5
| 5pts
|-
|-
| Moderate (bibasilar rales)
| Moderate (bibasilar rales)  
| 10
| 10pts
|-
|-
| Severe (pulm edema, A. fib)
| Severe (pulm edema, A. fib)  
| 15
| 15pts
|}
|}


'''VI. Precipitant history'''
'''VI. Precipitant history'''  


{| border="1"
{| border="1"
|-
|-
| Negative
| Negative  
| 0
| 0pts
|-
|-
| Positive
| Positive  
| 10
| 10pts
|}
|}


'''Scoring'''
'''Scoring'''  


*>45 = Highly suggestive of thyroid storm
*>45 = Highly suggestive of thyroid storm  
*25-44 = Suggestive of impending storm
*25-44 = Suggestive of impending storm  
*<25 = Unlikely to represent storm
*&lt;25 = Unlikely to represent storm


==DDX==
== DDX ==
#Infection
 
#Sympathomimetic ingestion (cocaine, amphetamine, ketamine)
#Infection  
#Heat exhaustion
#Sympathomimetic ingestion (cocaine, amphetamine, ketamine)  
#Heat stroke
#Heat exhaustion  
#Delirium tremens
#Heat stroke  
#Malignant hyperthermia
#Delirium tremens  
#Malignant neuroleptic syndrome
#Malignant hyperthermia  
#Hypothalamic stroke
#Malignant neuroleptic syndrome  
#Pheochromocytoma
#Hypothalamic stroke  
#Medication withdrawal (cocaine, opioids)
#Pheochromocytoma  
#Psychosis
#Medication withdrawal (cocaine, opioids)  
#Psychosis  
#Organophosphate poisoning
#Organophosphate poisoning


==Work-Up==
== Work-Up ==
*Chemistry
 
*CBC
*Chemistry  
*TSH/Free T3/T4
*CBC  
*Cortisol level (rule-out concurrent adrenal insufficiency)
*TSH/Free T3/T4  
*ECG
*Cortisol level (rule-out concurrent adrenal insufficiency)  
*Rule-out infection:
*ECG  
**CXR
*Rule-out infection:  
**CXR  
**Blood culture
**Blood culture


== Treatment ==
== Treatment ==
#Supportive care
 
##Fever
#Supportive care  
###Cooling measures, acetaminophen (avoid aspirin)
##Fever  
##Dehydration/hypoglycemia
###Cooling measures, acetaminophen (avoid aspirin)  
###D5NS (most pts have depleted glycogen stores)
##Dehydration/hypoglycemia  
##Cardiac decompensation (CHF, A-fib)
###D5NS (most pts have depleted glycogen stores)  
###Rate control, inotropes, diuretics as needed
##Cardiac decompensation (CHF, A-fib)  
#Block new hormone synthesis
###Rate control, inotropes, diuretics as needed  
##PTU 600-1000 mg PO or PR followed by 200-250mg q4hr
#Block new hormone synthesis  
###Preferred to methimazole b/c also blocks T4>T3 conversion
##PTU 600-1000 mg PO or PR followed by 200-250mg q4hr  
##Methimazole 20-25mg q4hr
###Preferred to methimazole b/c also blocks T4&gt;T3 conversion  
###Longer acting than PTU
##Methimazole 20-25mg q4hr  
#Block hormone release
###Longer acting than PTU  
##Wolff-Chaikoff effect: incr iodine concentration leads to transient decrease of T3/T4
#Block hormone release  
##Potassium iodide 5 gtt q6hr (Give 1hr after PTU)
##Wolff-Chaikoff effect: incr iodine concentration leads to transient decrease of T3/T4  
###1st line
##Potassium iodide 5 gtt q6hr (Give 1hr after PTU)  
##Lithium 300mg q6hr
###1st line  
###Consider if iodine allergic
##Lithium 300mg q6hr  
#Block beta-adrenergic tone and peripheral T4>T3 conversion
###Consider if iodine allergic  
##Propranolol PO 60-80 q4hr (if pt can tolerate PO)
#Block beta-adrenergic tone and peripheral T4&gt;T3 conversion  
##Propranolol IV 1mg over 10 min; if tolerates then 1-3mg boluses q3hr
##Propranolol PO 60-80 q4hr (if pt can tolerate PO)  
##Esmolol 250-500mcg/kg loading dose, then 50-100mcg/kg/min
##Propranolol IV 1mg over 10 min; if tolerates then 1-3mg boluses q3hr  
#Treat possible adrenal insufficiency (also blocks T4>T3)
##Esmolol 250-500mcg/kg loading dose, then 50-100mcg/kg/min  
#Treat possible adrenal insufficiency (also blocks T4&gt;T3)  
##Hydrocortisone 100-300mg IV bolus, followed by 100mg q8hr
##Hydrocortisone 100-300mg IV bolus, followed by 100mg q8hr


== See Also ==
== See Also ==
[[Hyperthyroidism]]
 
[[Hyperthyroidism]]  
 
== Sources  ==


== Sources ==
*Tintinalli  
*Tintinalli
*UpToDate  
*UpToDate
*Burch, HB, Wartofsky, L, Endocrinol Metab Clin North Am 1993; 22:263
*Burch, HB, Wartofsky, L, Endocrinol Metab Clin North Am 1993; 22:263


[[Category:Endo]]
[[Category:Endo]]

Revisión del 02:38 28 sep 2011

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

DDX

  1. Infection
  2. Sympathomimetic ingestion (cocaine, amphetamine, ketamine)
  3. Heat exhaustion
  4. Heat stroke
  5. Delirium tremens
  6. Malignant hyperthermia
  7. Malignant neuroleptic syndrome
  8. Hypothalamic stroke
  9. Pheochromocytoma
  10. Medication withdrawal (cocaine, opioids)
  11. Psychosis
  12. Organophosphate poisoning

Work-Up

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

Treatment

  1. Supportive care
    1. Fever
      1. Cooling measures, 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
  2. Block new hormone synthesis
    1. PTU 600-1000 mg PO or PR followed by 200-250mg q4hr
      1. Preferred to methimazole b/c also blocks T4>T3 conversion
    2. Methimazole 20-25mg q4hr
      1. Longer acting than PTU
  3. Block hormone release
    1. Wolff-Chaikoff effect: incr iodine concentration leads to transient decrease of T3/T4
    2. Potassium iodide 5 gtt q6hr (Give 1hr after PTU)
      1. 1st line
    3. Lithium 300mg q6hr
      1. Consider if iodine allergic
  4. Block beta-adrenergic tone and peripheral T4>T3 conversion
    1. Propranolol PO 60-80 q4hr (if pt can tolerate PO)
    2. Propranolol IV 1mg over 10 min; if tolerates then 1-3mg boluses q3hr
    3. Esmolol 250-500mcg/kg loading dose, then 50-100mcg/kg/min
  5. Treat possible adrenal insufficiency (also blocks T4>T3)
    1. Hydrocortisone 100-300mg IV bolus, followed by 100mg q8hr

See Also

Hyperthyroidism

Sources

  • Tintinalli
  • UpToDate
  • Burch, HB, Wartofsky, L, Endocrinol Metab Clin North Am 1993; 22:263
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