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Thyroid Storm | Dr Rizwan Qureshi

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Thyroid storm is a life threatening emergency that is difficult to diagnose mainly because it is overshadowed by underlying factors.

My name is respon and i’m an emergency physician and today i’m going to talk about thyroid storm a life-threatening form of all hyper thyroid states what makes hard rock stone interesting is that it’s diagnosed clinically what makes solid stone complicating is that it’s hidden behind its underlying triggers i’m going to present to you two relevant clinical cases

Which will help us face the clinical discussion around the diagnosis and its management at the end we’ll do a quiz if we already am well prepared so without further ado let’s jump right into it first case involves a 70 year old gentleman who came to emergency in severe respect distress he was technic it was also hypoxic and starts about 88% in room air it was

Also taking kartik in fast atrial fibrillation with a rate of about 145 a minute and had a systolic blood pressure of 80 he was febrile with the temperature of 40 degrees celsius and was quite confused and disoriented it was difficult to judge whether his condition is because his fast ef is pushing him in a dq pulmonary edema or whether it’s all just sepsis the

Second case is quite different it’s a 41 year old lady previously written well who was recently flown in from a long-haul flight and now presenting with the week’s history of exertional dis nia she was taking tonic at hundred-ton and ecg shows sinus tachycardia but she was not hypoxic and had normal oxygen saturation so when the blood results came back both patients

Had non existent thyroid stimulating hormone and grossly elevated t3 and t4 howard what’s interesting is that with very similar-looking thyroid function test results the elderly patient was in thyroid storm and the younger female patient was in thyrotoxicosis so we’re going to talk about the clinical hyperthyroidism why it happens the reason it happens is either

Because of the overproduction of thyroid hormone or an excessive response to the thyroid hormone and clinically it manifests in one of three states number one harper thyroid state in which the gland is all producing the florid hormone t3 and t4 are being over produced in excessive amounts and you get the clinical effects of the thyroid number two thyrotoxicosis

In which there’s an excessive amount of thyroid hormone which could be because of the gland overproduction it could be because of an overdose in thyroid medication or any other cause from that matter and number three that we’re more interested in today is thyroid storm now thyroid storm is severe life-threatening form of thyrotoxicosis in which this adrenergic

Hyperactivity basically what happens is that thyroid hormone is exerting its peripheral effects by altering the receptors and getting them to generate an adrenergic crisis which we see in a form of cardiovascular symptoms and catastrophes in neurology symptoms think it has to be like seizures and coma and we’ll focus our discussion on this topic today so why

Does tyroid storm happens well there number of different conditions which can trigger a thyroid storm some of the most common conditions include infections chest infections pyelonephritis metabolic emergencies like diabetic ketoacidosis hyperglycemic hyperosmolar non-periodic states also conditions like pulmonary embolism acute myocardial infarction and cba can

Trigger thyroid storm crises the other common conditions include overdose on thyroid medication or sudden or abrupt withdrawal of thyroid medications also trauma stress and surgeries are enough to trigger off the thyroid storm obstructive emergencies are other common cause so how does tyroid storm present what alright storm is a clinical diagnosis in someone who is

Hyper thyroid for example someone who’s taking thyroid medications and also high fever is a cardinal feature of thyroid stone no sink at all right storm is a condition in adrenergic crisis state with neurologic and cardiovascular manifestations so cardiovascular science would be on the likes of palpitations tachycardia atrial fibrillation the patients may go into

An acute pulmonary edema and may develop a purulent pericardial rub and sometimes also water hammer pulse the the neurologic manifestations are quite random the patient may be initially agitated and confused may go on and develop a seizure and may have prolonged drowsiness and coma in a thyroid storm is a clinical diagnosis specially in someone who’s already on

Thyroid medications remember when you give an endocrinologist call at thinking that look this patient might have a thorough toxic state based purely on the biochemical results but that’s not the case so if the patient has got those gross abnormality in terms of energy crisis cardiovascular science in europe neurologic signs plus a low tsh and very high t3 and t4

Then the patient has got thyroid storm you might like to do in ecg which may show a tachyarrhythmia sinus tachycardia atrial fibrillation or any other form of supraventricular it’ll written the patient may also have the investigation suggestive with an underlying trigger like we’ve talked about infections the metabolic triggers like dka or hyperglycemic hyperosmolar

States and also sometimes vascular pathak state like the patient might be having a stroke or acute my current action or maybe having a pe so just be on the lookout for those underlying triggers which might be a predominant features in the patient’s presentation and the thyroid storm may be overshadowed before i go into the specific of thyroid storm management let

Me highlight these patients are generally very sick because the underlying trigger they might be septic they may have taken dysrhythmias they being flash pulmonary oedema or they may have other crises like pe or acute myocardial infarction or dka so it’s very important that we stabilize these patients in resuscitation area now if they’re in shock they need to be

Treated with intravenous fluid judiciously if they are elderly and susceptible to the volume overload but also carefully that they need dextrose to replenish those glycogen stores now word of caution the patients who are alcoholics and you treat them with dextrose they can develop wernicke’s and careful obvi so it’s very important these patients are actually pre

Treated with thymine now these patients may have very high fever and that needs to be cooled down any of the external cooling measures evaporative method cooling fans can be tried the other thing is that you can try medications like paracetamol but don’t give aspirin because it increases the free t4 levels so the specific management of thyroid storm is based on

For blockages number one blockage is to block on the release of the thyroid hormone from the thyroid gland and that can be done by giving them dynamites like propulsor aerosol and methimazole the second step is the blockage of the production that can be done by giving them iodine lugol’s iodine or lithium even the third step is actually preventing or blocking the

Peripheral conversion of t3 t4 to t3 so t3 is much more active form and by doing them steroids like hydrocortisone or dexamethasone we are preventing the conversion of more t4 to more activity 3 so that’s very important and the last step is to inhibit peripheral receptors block those peripheral receptors which are causing all those taking kartik responds by giving

Propranolol so the important step here to realize is that release of thyroid hormone from the gland with propylthiouracil and methimazole is the first step that must be done before the blockage of the production of thyroid hormones by the gland which is done by the iodine or lithium so in summary tonight’s storm is a clinical diagnosis with its cardinal features

Of high fevers and commonly techie rithmere most likely a sinus tachycardia or natal fibrillation most of its signs and symptoms are exerted by adrenergic cardiovascular responses and neurologic responses most of the triggers are because of infection metabolic state and vascular pathak states like pe mi and stroke also remember 25 percent of the cases you may not

Be able to find the underlying trigger an important management issue in the management of thyroid storm is to block the release of thyroid hormone by using tiny mites like ptu and methimazole before blocking the production of thyroid hormone by using iodine or lithium now this is a very crucial management aspect that we must remember also you must remember that if

The patient is presenting with severe tachycardia and it’s a population do not ever use em your own to control that heart rate because it made self cause thyroid storm also if you’re suspecting that m your own is the trigger of the thyroid strong then do not use iodine to block the production of thyroid hormone in second step of its management now just putting it

Out there with the thyroid hormone is released and absorbed blockage of an entire hepatic circulation is also one of the main management aspects in some of the patients in thyroid storm tyroid crisis i hope you liked the presentation on thyroid storm its identification and management in emergency department now if you think that you are ready one to take our quiz

Of thyroid storm management and stop some crucial points and explanation

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Thyroid Storm | Dr Rizwan Qureshi By Emergency Focus