Thyroid Crises - Thyroid Coma and Thyroid Storm
Suspect in patients with known thyroid disease with a trigger: surgery, trauma, infection, trauma, pregnancy, iodine load, hypo/hyperthermia, meds. Labs cannot differentiate between severe and crisis states. Classic signs (above) tell you about chronicity, but not necessarily severity. AMS required for crisis (usually hemodynamically unstable). Mortality >30%. STAT endocrine consult.
• Hypothermia, bradycardia, ventricular arrhythmias, HypoTn
• Most common cause of death is hypercapneic resp failure
• Careful with IVF if hypoNa. Patients are hypometabolic: use lower drug doses at lower frequency, avoid MS-altering meds.
• Test and Empirically Treat AI: If concern for AI, give hydrocort 50-100mg before thyroid hormone (if concomitant AI, replacing thyroid hormone first will catabolize residual cortisol and cause hypoTN/death)
• Tx: T4 12.5-50mcg IV QD in elderly or at risk for MI, up to 200mcg if sick and young. T3 (5-10mcg Q8H) only given if pt is critically ill (T4 conversion to T3 takes several days), give only with endo guidance, can cause rebound hypermetabolism
• Recheck FT4 in 3-7d; if giving T3, monitor peak levels
• Hyperthermia, tachycardia, tachy-CM, atrial arrhythmias, HyperTn
• Treat the underlying precipitant
• Patients are hypermetabolic and will clear drugs quickly
• BB: Only propanolol decreases T4→T3 conversion, may require high doses (2g/day). Titrate to sx and HR (i.e. <80).
• Anti-Thyroid Meds: Only stop formation of new hormone, not release of stored hormone. Methimazole (20mg Q4-Q6) is preferred unless pt is critically ill. PTU (200mg Q4-Q6) decreases T4→T3 but higher rates of fulminant hepatic necrosis. Iodine (100-250mg Q6-Q8H) must be given at least 1hr after thionamide; can cause Jod-Basedow in toxic adenoma and Wolff-Chaikoff in Graves.
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