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... 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! . Ch 215 Hyperthyroidism & Thyroid Storm Carrie L. Lotenero, DO September 27 th , 2007 Causes of Thyrotoxicosis • Primary hyperthyroidism – Graves dz – Toxic. intake • Central hyperthyroidism – Pituitary adenoma Causes of Thyrotoxicosis • Thyroiditis – Subacute painful (de Quervain) – Silent subacute – Postpartum – Radiation thyroiditis • Non-thyroidal. thyroiditis • Non-thyroidal dz – Ectopic thyroid tissue – Metastatic thyroid CA • Drug-induced – Lithium – Iodine – Amiodarone – Excessive TH ingestion Sx of hyperthyroidism • Weakness • Fatigue • Heat