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THYROID STORM
- Etiology
- Graves (60-80%), toxic adenoma, thyroiditis
- Precipitants: infection, surgery, CVA, MI, PE
- Sx/PE
- Fever (may be >40C), sinus tachycardia/supraventricular arrhythmias +/- high output heart failure
- Agitation/psychosis/seizures, diarrhea/vomiting/jaundice
- May be evaluated using Burch-Wartofsky score
- Diagnosis
- low TSH, high FT4= primary thyrotoxicosisà US, RAIU
- low TSH, nl FT4, high FT3= T3 toxicosis
- nl/high THS, high FT4= pituitary adenoma
- Tx
- Decrease hormone synthesis
- PTU (also inhibits peripheral T4à T3 conversion) 500-1000mg load PO/IV, then 250mg Q4h (avoid in liver dysfunction) or
- Methimazole 29mg PO every 4-6 hours
- Corticosteroids (prophylaxis against relative adrenal insufficiency): hydrocortisone 300mg IV load, then 100mg IV Q8
- B-blockade (block peripheral effects of hormone): propranolol 60-80 Q4hr or esmolol gtt
- block release/synthesis of hormone: potassium iodide 5 drops PO Q6hr; start 1 hr after antithyroid drug
- Supportive care: volume resuscitate, respiratory support PRN
- Antipyretics: APAP, cooling blanket. AVOID salicylates!
- Decrease hormone synthesis
MYXEDEMA COMA
- Definition: hypothyroidism + stupor/confusion/coma + hypothermia + low T4 and T3
- Sx/PE: poor memory, apathy, weakness (hypercapneic respiratory failure), fatigue, cold intolerance, constipation (can progress to ileus), dry skin, menstrual irregularities, bradycardia, hypoNa, hypoglycemia,
- Tx BEFORE LABS RETURN! MORTALITY IS 30-40%
- 1st= glucocorticoids (give bc decreased adrenal reserves)- hydrocortisone 50-100 mg IV Q 6-8hrs
- 2nd= thyroid hormone (type is controversial)
- T4: IV 4mcg/kg, then 100mcg IV at 24 hrs, then 50 mcg/day IV or
- T3: 10 mcg IV Q 8-12hrs until pt begins PO T4
- Caution in older pts and pts with CAD and arrhythmia.
- Correct hypovolemia, hyponatremia, PRN vasopressors