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Thyroid Emergencies PowerPoint Presentation

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Description : Check out this medical PowerPoint presentation titled "Thyroid Emergencies" by Heidi Chamberlain Shea, MD.

This medical PowerPoint presentation talks about thyroid emergencies which are relatively rare but potentially life-threatening conditions that require immediate medical attention. These emergencies occur when the thyroid gland, a butterfly-shaped gland located in the neck, produces too much or too little thyroid hormone. There are three main thyroid emergencies: thyroid storm, myxedema coma, and subacute thyroiditis.

Tags : thyroid emergencies, thyroid storm, myxedema coma, subacute thyroiditis, endocrinology, endocrinology PowerPoint presentation

Published on : Apr 24, 2023 | Views : 1608 | Downloads : 7

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Slide 1-

Thyroid Emergencies Heidi Chamberlain Shea, MD Endocrine Associates of Dallas
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Thyroid Trivia Largest endocrine gland 20 grams in adult Each lobe 2-2.5cm in width and thickness 4cm in height Isthmus 0.5cm thick 2cm height and width Named for the relationship to the laryngeal thyroid cartilage Resembles a Greek shield
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Thyroid Hormone Synthesis Iodide trapping Oxidation of iodide and iodination of thyroglobulin Coupling of iodotyrosine molecules within thyroglobulin (formation of T3 and T4) Proteolysis of thyroglobulin Deiodination of iodotyrosines Intrathyroidal deiodination of T4 to T3
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Thyroid Hormones T4 ( Tetraiodothyronine ) T3 ( Triiodothyronine ) , Reverse T3 T3 T4
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Goals of Discussion Hypothryoidism Clinical symptoms Myxedema Coma Definition Treatment Hyperthryoidism Clinical symptoms Thyroid Storm Definition Treatment
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HypothyroidismSymptoms Nervous system Forgetfulness and mental slowing Paresthesias Carpal tunnel Ataxia and decreased hearing Tendon jerk slowed with prolonged relaxation phase Cardiovascular Bradycardia Decreased cardiac output Pericardial effusion Reduced voltage on EKG and flat T waves Dependent edema
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HypothyroidismSymptoms Gastrointestinal Constipation Achlorhydria with pernicious anemia Ascitic fluid with high protein Renal Reduced excretion of water load Hyponatremia Decreased renal blood flow and glomerular filtration Pulmonary Responses to hypoxia and hypercapnia are decreased Pleural effusions high protein Musculoskeletal Arthralgia Joint effusions Muscle cramps CK can be elevated Anemia Normochromic normocytic Megaloblastic Pernicious anemia
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HypothyroidismSymptoms Skin and hair Loss of lateral eye brows Dry, cool skin Facial features Coarse and puffy Orange skin Carotene Reproductive system Menorrhagia from anovulatory cycles Hyperprolactinemia No inhibition of thyroid hormone Metabolism Hypothermia Intolerance to cold Increased cholesterol and triglyceride Decreased lipoprotein receptors Weight gain
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Myxedema ComaDiagnosis Altered mental status Decreased orientation Increased lethargy Confusion/psychosis May be secondary to Stroke Medication effect Sepsis CO2 narcosis
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Myxedema ComaDiagnosis Defective thermoregulation Normal body temperature with sepsis Age Most are elderly Decreased ability to compensate Precipitating illness or event Exclude pulmonary or urinary tract source Trauma Stroke Hypoglycemia Hypothermia CO2 narcosis Diuretics Sedatives Tranquilizers Drug overdose
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Myxedema ComaManagement When in doubt, treat Mortality 30-40% ICU setting Lab tests TSH, T4, T3-uptake, Cortisol, CBC with diff and routine chemistries Blood, sputum and urine cultures WBC may not be elevated Bands present of other concerning finding, empiric treatment is appropriate
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Myxedema ComaManagement Body temperature support Poikilothermic No aggressive warming Vasodilatation= vascular collapse Passive warming Respiratory support Intubation may be needed If HCT <30%, transfuse Provide adequate perfusion and oxygen carrying capacity
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Myxedema ComaManagement Cardiovascular support Fall in blood pressure is ominous Look for GI bleed, MI, over diuresis or iatrogenic vasodilatation Endocrine support Hydrocortisone 100 mg Q8 hrs Treat possible coexisting primary or secondary adrenal insufficiency Stop once cortisol level is confirmed to be normal
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Myxedema ComaManagement Thyroid hormone therapy 300-500 ug IV Levothyroxine x1 50-100 ug IV Qday Lower doses for smaller people or older at risk for cardiac events IV to bypass poor absorption in the bowel Alternately give T4 and T3 due to decreased T3 conversion 200-300 ug T4 then 50 ug/day 5-20 ug T3 then 2.5-10 ug Q8 hrs
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Myxedema ComaManagement Addition of Levothyroxine causes Increase in cardiac index 1-2 days TSH falls 32% in 24 hrs Serum T3 levels increased on 3rd day Reversal of blunted ventilatory responses 7 days
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Myxedema ComaManagement Obtain Free T4- 3 days after initiation of therapy to make sure it is increasing Adjust to normalize value Once tolerating PO can change to oral therapy Increase IV dose by 40% for oral dosing ie: IV 100 mcg then 140 mcg PO
Slide 17-

Hyperthyroidism
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HyperthyroidismSymptoms Nervousness/Anxiety Weight loss Increased hunger Heat intolerance Cardiac Atrial fibrillation Palpitations Increased stool frequency Decreased concentration Weakness Fatigue Decreased sleep Irritablity Change in menstrual patterns Infiltrative orbitopathy Exopthalmos Goiter 20% elderly no goiter 3% normal size
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Hyperthyroidism Cardiac Sinus tachycardia 15% atrial fibrillation Increased cardiac output 2-3 times normal Nervous system Diaphoresis Tremor
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Hyperthyroidism Increased metabolic rate Increased blood flow to tissues by vasodilatation T3 affects smooth muscle tone Systemic vascular resistance is decreased by 50% Decreased diastolic blood pressure Increased rate and force of cardiac contraction Increased erythropoietin = increased blood volume
Slide 21-

HyperthyroidismLab Tests TSH Free T4 If done by RIA can be falsely elevated Gold standard equilibrium dialysis T4 and T3 uptake T3 Thyroid stimulating immunoglobulin (TSI AB) TSH suppressed with increase in T3 and T4
Slide 22-

Thyroid StormDiagnosis Decompensation of function due to symptoms Hyperthermia CNS effects Delirium, psychosis, coma, seizure Cardiac Tachycardia Heart failure Abnormal rhythm GI/Liver dysfunction Jaundice Diarrhea, nausea, vomiting and abdominal pain
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HyperthyroidismTreatment B-adrenergic blockade Use cautiously in asthmatics and diabetics Improves Tachycardia Widens pulse pressure Decreases palpitations Anxiety Sweating Propranolol Some decrease in T4 to T3 conversion 20-40 mg Q4-6hrs Atenolol or Metoprolol Longer acting
Slide 24-

HyperthyroidismTreatment Thionamide medications Block the thyroid hormone synthesis by blocking organification of iodine Propylthiouracil (PTU) Blocks peripheral conversion of T4 to T3 in liver and kidney 300-600 mg Q8 hrs Methimazole (Tapazole) 30-60 mg Q8hrs, BID or QD
Slide 25-

Thyroid StormManagement ICU setting Mortality of 20-30% Obtain thyroid function tests Load PTU oral 1000 mg x1 then 200-250 Q4 hrs. Rectal administration Use Tapazole 30 mg Q6hrs Rectal administration Side Effects Rash, arthralgia, serum sickness, abnormal liver function tests and agranulocytosis Sodium ipodate and iopanoic acid Radiographic contrast agents Potent inhibitors of T4 to T3 conversion Structurally similar to thyroxine 1 gram daily Decrease T3 in 24-48 hours Continue for 7-14 days
Slide 26-

Thyroid StormManagement Inorganic iodine Blocks thyroid hormone release Lugol’s solution (8 drops) or saturated solution of potassium iodide (SSKI) (6 drops) Q6 hrs. Can dilute and give as a retention enema Give iodine one hour after thionamides Lithium Patient’s with iodine allergy 300 mg Q6 hrs Titrate to level of 1 mEq/L Renal and neurological toxicity impair lithium’s usefulness
Slide 27-

Thyroid StormManagement Corticosteroids Decrease secretion of thyroid hormone and decrease T4 to T3 conversion Hydrocortisone 100 mg Q8 hrs Dexamethasone 2 mg Q6 hrs Use for 2 weeks
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Thyroid StormManagement B-adrenergic blockade Need higher doses Propranolol 0.5 to 1.0 mg initially with monitoring up to 2-3 mg in 1 minutes 60-80 mg oral every 4 hours Esmolol loading 250-500 μg/kg 50-100 μg/kg/minute Can use diltiazem and guanethidine Asthma and heart failure With tachyarrhythmia can use loading propranolol
Slide 29-

Thyroid StormManagement Hyperthermia Cooling blankets Acetaminophen Avoid aspirin Can displace thyroid hormones from binding proteins Fluids 3-5 liters per day Include glucose and thiamine Depletion of liver glycogen and thiamine deficiency Congestive heart failure Diuretics Digoxin Requires higher doses in thyroid storm
Slide 30-

Thyroid StormManagement Look for precipitating event All febrile patients should be cultured Unless source found, no empiric treatment needed Once stable and T4 levels are decreasing can decrease dosing of thionamides
Slide 31-

Hyperthyroidism Limit activity In patients with heart disease Increased risk of heart failure Young patients High output failure Increased circulating volume During exercise not able to increase LVEF Not able to further decrease SVR
Slide 32-

Conclusion Myxedema coma Critical samples Passive warming Load Synthroid Daily IV Start Hydrocortisone Look for inciting event Thyroid storm Critical samples Control heart rate B-blockade Calcium channel blockade Thionamide therapy Look for inciting event