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You are here: Home / 09. Medical/Surgical / endocrinology / Thyroid Disorders

Thyroid Disorders

July 14, 2011 by CrashMaster

Thyroid

Best Panel for Critically Ill

TSH, Total T4, T3 Uptake or

TSH, Total T4, Free T4

 

Confirmatory tests (normal T4 and suppressed TSH or Amiodarone patients):  get Total/Free T3

Hyperthyroid Storm

fever, tachycardia, tremor, systolic flow murmur, A-Fib

can also be from exogenous thyroid replacement hormone

 

ask about stressors: thyroid manipulation, med changes, trauma, infections, exertion, anesthesia, iodinated contrast

 

Diagnosis

>45 is almost surely storm, 25-44 is suggestive, <25 is unlikely

(Endocrinol Metab Clin North Am. 1993 Jun;22(2):263-77.) do not give ASA

 

Rx

 

Step I

Start a beta blocker

PO propanolol if stable

Esmolol drip if not

Step II

Antithyroid meds

PTU 1000 mg PO load then 250 mg Q4-6 (1200 mg per day)

OR

MMI 20 mg PO or PR Q4 hours

 

AND

Dexamethasone 2 mg IV Q6

 

Step III

then iodide (at least 1 hr after PTU/MMI)

 

 

 

Propylthiouracil PO/NG/PR 1 g x1 Blocks Gland formation and conversion     250 mg Q4-6   MMI PO/NG/PR 20 mg Q4 hrs   Iopanoic Acid PO 1 G Q8   SSKIPO/NG 8 Drops Q6   Lugol’s Solution PO/NG 8 drops Q6 Blocks hormone release Potassium Iodide PO/NG 1 Tab QD Blocks hormone release Lithium Carbonate PO/NG 300 mg Q6   Propranolol PO/NG 40-80 mg Q 4-6 Blocks peripheral effects   IV 1 mg Q2 PRN Max 10 mg   Atenolol PO/NG 25-100 mg QD Blocks peripheral effects   IV 5 mg Over 5 min   Esmolol IV .5/kg bolus .05-.1 mg/kg/min Blocks peripheral effects Reserpine IM 1-2.5 mg Q6   Hydrocortisone IV 100 mg Q8 Blocks Peripheral Conversion Dexamethasone PO/IV 2 mg Q6 Blocks Peripheral Conversion Prednisone PO/NG 1 mg/kg QD Blocks Peripheral Conversion

 

may need hemodialysis

 

high dose propranolol may not be the most clever move as the patient may have a longstanding cardiomyopathy from the thyroid and when pt’s hormones go down, they can crash from the long beta blockage. Esmolol is probably the most 2nd most clever way to go.

 

From EM:RAPDx

1. Hyperthyroid History

2. Fever, pt’s can’t vasodilate

3. Cognitive Changes

4. Something that predisposes to sympathetic response

 

Young people handle this worse b/c they have more receptors

 

Always screen for infection

CBC, T4, TSH, Pan Cx

May have a low Cr because they can’t convert creatine to Cr

Low PLt

Hb in the range of 12

PTU 150 Q8

1 hour later, 10 drops of KI

Decadron 4 mg IV Q6

 

Inderal IV only has 1/2 life of 5 min

give 1 mg test dose

then give in 1-2 mg increments

then start on 3-5 mg/hr

shoot for HR of 90-100

beta 3 receptors effect metabolic rate

 

Review

Hypothyroidism

Hypothermia, weight gain, constipation

5% of carpal tunnel is hypothyroid

500 mg T4 orally or IV, give stress does of steroids as well.

Myxedema Coma

Rx:

Supportive Care

Levothyroxine 300 to 500 ug IVPB then 50 to 100 ug IV OD

T3 25 ug IV/PO Q8

Consider Hydrocortisone 100 mg IV Q8 before thyroid replacement (Draw Cortisol first if possible)

 

Thyroid hormone — The optimal mode of thyroid hormone therapy in patients with myxedema coma is controversial, largely because the condition is so rare that there are no clinical trials comparing the efficacy of different treatment regimens. While increasing serum thyroid hormone concentrations rapidly carries some risk of precipitating myocardial infarction or atrial arrhythmias, this risk must be accepted because of the high mortality of untreated myxedema coma. There is disagreement about the preferred thyroid hormone regimen, but both very high and very low doses seem less effective than intermediate doses [14]. Some experts favor administration of triiodothyronine (T3), because its biologic activity is greater and its onset of action is more rapid than T4. An additional consideration is that the conversion of T4 to T3 is impaired due to both hypothyroidism and any concurrent nonthyroidal illness. Proper dosing is important. High serum T3 concentrations during treatment have been correlated with mortality [13]. Others prefer T4, which should be given intravenously because gastrointestinal absorption may be impaired [15]. The first dose should be large: 200 to 400 mcg (0.2 to 0.4 mg), with the exact dose being dependent upon the patient’s weight and age and the likelihood of complications such as myocardial infarction or an arrhythmia. In one randomized trial of 11 patients, those who received a 500 mcg loading dose followed by 100 mcg daily had a lower mortality than those treated with 100 mcg daily without a loading dose; however, the difference did not reach statistical significance [16]. Thus, the dose should be reduced in lighter and older patients and those at risk for cardiac complications. Daily doses of 50 to 100 mcg are given thereafter, initially intravenously and, when feasible, orally. (See “Treatment of hypothyroidism” for a discussion of chronic therapy). We prefer to give both hormones [17]. T4 is given in a loading dose of 200 to 300 mcg followed by 50 mcg daily. T3 is given simultaneously in a dose of 5 to 20 mcg, followed by 2.5 to 10 mcg every eight hours depending upon the patient’s age and coexistent cardiac risk factors. T3 is continued until there is clinical improvement and the patient is stable. Supportive measures — Supportive measures are extremely important in the treatment of patients with myxedema coma and, in the first day or so, may make the difference between survival and death. These measures include treatment in an intensive care unit, mechanical ventilation if necessary, judicious administration of intravenous fluids including electrolytes and glucose, correction of hypothermia, and treatment of any underlying infection. Dilute fluids should be avoided in hyponatremic patients to prevent a further reduction in the plasma sodium concentration. Hypotension, if present and not caused by volume depletion, will be corrected by thyroid hormone therapy over a period of hours to days. Severe hypotension that does not respond to fluids should be treated with a vasopressor drug until the T4 has had time to act. Passive rewarming with a heating blanket is preferred for correction of hypothermia. Active rewarming carries a risk of vasodilatation and worsening hypotension. As with any critically ill, comatose patient, empiric administration of antibiotics should be considered until appropriate cultures are proven negative.

 

 

Myxedema almost always has a cpk>500

winter months

sed/hyp and psych drugs

amiodarone

diuretics

 

 

labs to send tsh, free t4, total t4delayed dtr, low wbc with lymphocytic predominencethey will all have altered mental status of some ilk if they are myxedematous, better to call it decompensated hypothyroidismgive 500 mcg of T4mostly anemicfluid downgive hydrocortisone firsthyponatremiagive betablockers for thyroid paralysis

 

Euthyroid Sick Syndrome

thyroid function abnormality from illness or stress without underlying thyroid disease.

Probably from cytokine interactions

Initially low levels of T4 and T3 with normal TSH, eventually TSH will decline as well

 

 

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Filed Under: endocrinology


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