82

2 LLQ .

3
ceftazidime
CT abdomen : bowel ileus, H/C no growth
Sulperazon with metronidazole
refer .

BT 38.0oC, HR 104 , RR 20/min, BP 126/60 mmHg

Mild pale, no jaundice, no exophthalmos
Thyroid can not palpable
Systolic ejection murmur grade III at RUPSB
radiate to neck
No pretibial myxedema
No onycholysis

 Hct 27.1 % MCV 80 RDW 17.0 WBC 4,020 N 68.9

L 21.9 Eo 1.7 % Plt 20,000
Occult blood positive
PT 20.6/12.5 INR 1.8 PTT 28.4/31.4
UA 1.015 protein and sugar RBC1-2 WBC3-5
BUN 4 Cr 0.26 Na 138 K 3.6 Cl 102 HCO3 27

 TB 0.59 SGOT 20 SGPT 13 ALP 62

Albumin 1.9 Globulin 3.0 g/L
EKG NSR 97/min, no LVH

1. Subacute fever with abdominal pain

2. Bicytopenia
3. Aortic stenosis
FT3 4.38 (1.6- 4.0 pg/mL), FT4 2.81 (0.8-1.8 ng/dL)
Do you forgot thyroid function test?
TSH 0.005 (0.3-4.1uIU/ml)

 PTU(50) 4 tab oral q 4 hr with stat (1200-1500 mg/d)

SSKI 4 drops oral q 12 hr 1 hour after PTU (200-500
mg/d x 1-2 weeks) (SSKI 38 mg/drop = 0.05ml)
Dexamethasone 4 mg iv q 12 hr with stat (8-12 mg/d x
3-4 d)
Thiamine 100 mg iv od
Paracetamol(500 mg) 1 tab oral prn q 6 hr
beta blocker amiodarone notify

 Older patients may present with some atypical

symptoms including weight loss, palpitations,
weakness, dizziness, syncope, or memory loss,
and physical findings of sinus tachycardia or AF

Endocrinol Metab Clin North Am 2006;35(4):663-86

Graves disease
Solitary toxic adenoma
Toxic multinodular goiter
Thyrotropin-secreting pituitary adenoma
Thyroid carcinoma
Subacute thyroiditis
Struma ovarii/teratoma
hCGsecreting hydatidiform mole
Interferon alpha and Interleukin-2induced thyrotoxicosis
Endocrinol Metab Clin North Am 2006;35(4):663-86

Score

Score

Cardiovascular dysfunction
Temperature(oF) (oC/5=(oF-32)/9)
Tachycardia
5
99-99.9
10 90109
5
100-100.9
15 110119
10
101-101.9
20 120129
15
102-102.9
25 140
25
103-103.9
30
Congestive heart failure
104
0
Absent
Central nervous system effects
0 pedal edema
5
Absent
10 bibasilar rales
10
Mild agitation
20 pulmonary edema
15
Delirium, psychosis, lethargy
30
Atrial fibrillation
Seizures, coma
0
Absent
GI-hepatic dysfunction
0 Present
10
Absent
10
Precipitating event
Diarrhea, nausea/vomiting, abdominal
Absent
0
pain
20 Present
10
Unexplained jaundice
< 25 is unlikely, 25-44 impending storm, 45 is highly suggestive of thyroid storm
Endocrinol Metab Clin North Am 2006;35(4):663-86

Infection
Acute medical illness
Trauma
Surgery (thyroid &
nonthyroid)

Iodine contrast
administration
Parturition
After 131I
Thyrotoxicosis factitia
Acute psychosis

Werner & Ingbar's the thyroid : a fundamental and clinical text, 9th ed

 32-year old Singaporean man with bilateral pitting

edema and atrial flutter was given oral propranolol 10
mg. He became cardiovascular collapse 4 hr later
28-year-old Singaporean man with CHF for 1 week
with atrial fibrillation. Both propranolol and digoxin
were commenced but he subsequently collapsed
The Author suggest avoiding propranolol in patients
who may have long standing hyperthyroidism or CXR
showing cardiomegaly
Resuscitation 2007;73(3):485-90

 Miss diagnosis: apathetic thyrotoxicosis, sepsis

unconscious, heart failure, hepatic
encephalopathy, seizure, stroke, trauma
Miss interpretation of thyroid function results
FT3 3.26 (1.6- 4.0 pg/mL), FT4 3.53 (0.8-1.8 ng/dL)
TSH 0.016 (0.3-4.1uIU/ml)

Undiagnosed precipitating factors

 Steroid avoidance
Cardiovascular collapse from -blocker
Rectal suppositories were not retained

Clinically, it is prudent to assume that someone

with severe thyrotoxicosis has impending thyroid
storm, and to treat them aggressively, rather than
focus on specific definitions

Endocrinol Metab Clin North Am 2006;35(4):663-86

 Ultimate stage of severe longstanding

hypothyroidism
Most patients are not comatose
Diagnosis : marked stupor, confusion or coma in
a patient with a history and physical finding of
hypothyroidism, esp. hypothermia
Rev Endocr Metab Disord 2003;4(2):137-41

 The mortality rate change from 60-70% to 20-25%

~ 5% of myxedema coma, the underlying cause is
hypothalamic or pituitary disease
The magnitude of TSH elevation or FT4
decrement do not correlate well with severity of
the clinical presentation
Endocrinol Metab Clin North Am 2007;36(3):595-615 ; Endocrinol Metab Clin North Am 2006;35(4):687-98
J Intensive Care Med 2007 Jul-Aug;22(4):224-31

 79
CC : 2
PI : 1
Hx &
2 no orthopnea, no PND PE ?
PE : BT 36.0 RR 12 HR 70 BP 130/70 drowsiness
E4V4M6, inspiratory stridor, macroglossia,
moderately pale, thyroid gland normal, myoedema

 Lethargy, slowed mentation, poor memory,

cognitive dysfunction, depression, or even
psychosis
Focal or generalized seizures

Endocrinol Metab Clin North Am 2006;35(4):687-98

 Nonpitting edema of
Dry, coarse, scaly
the hands and feet
skin
Sparse or coarse hair Macroglossia
Delayed deep tendon
Hoarse voice
reflexes to areflexia
Periorbital edema
Paralytic ileus
Williams textbook of endocrinology, 11th ed. ; Endocrinol Metab Clin North Am 2006;35(4):687-98

 Hypoventilation
Moderate to profound hypothermia
Bradycardia, and reduced cardiac contractility
Cardiomegaly from ventricular dilatation or pericardial
effusion
Frank congestive heart failure is rare

Hypotension because of decreased intravascular

volume
Endocrinol Metab Clin North Am 2006;35(4):687-98

Hypothermia
Infections
Cerebrovascular accidents
Congestive heart failure
Anesthetics
Sedatives, Narcotics
Amiodarone, Lithium

Gastrointestinal bleeding
Trauma
Metabolic disturbances:
Hypoglycemia,
Hyponatremia, Acidosis,
Hypercalcemia, Hypoxemia,
Hypercapnia

Endocrinol Metab Clin North Am 2006;35(4):687-98

 79
CC : 2
PI : 1
2 no orthopnea, no PND
PE : BT 36.0 RR 12 HR 70 BP 130/70 drowsiness
E4V4M6, inspiratory stridor, macroglossia,
moderately pale, thyroid gland normal, myoedema
Order?

 Admit ICU,
EKG,
UA,
cortisol,
NG
drip
What was missing from the order?

Admitted to ICU and EKG monitoring

Assisted ventilation 24-48 hours
External warming should be avoided
Frequent turning
Prevention of aspiration
Attention to fecal impaction and urinary retention
Williams textbook of endocrinology, 11th ed.

 FT4 < 0.02 ng/dL, TSH > 100 mU/mL

ABG room air: pH 7.186, PCO2 54.6, PaO2 33.2,
HCO3 20.2, O2 sat 49.9 %
Hct 24.9 % WBC 6300 N 57% L 29% Plt 119,000
Stool occult blood positive
UA sp.gr 1.020, no cell

 Na 112 K 4.2 Cl 78 HCO3 19 AG 15

Cr 1.7

Order?

 BW ~ 70-80 kg
Serum Na
8 mEq/L in
6 hours
steroid 1
PRC before thyroxin

What was missing from the order?

 Asymptomatic mild hyponatremia (> 120 mEq/L)

can be monitored without specific therapy
because it usually resolves with thyroxine
therapy

Crit Care Clin 2001;17(1):59-74

 Production of cortisol is reduced in

hypothyroidism
Peripheral degradation of hormone is retarded
Excretion of cortisol metabolites in the urine is
reduce
Overall effect is normal concentration of cortisol
in plasma
The American Journal of The Medical Scinces 1972;264(6):433-43

 Hydrocortisone usually is given intravenously

(50100 mg every 6 to 8 hours for several days)1
All patients should be given stress-dose steroids
for the first 24 - 48 hours2

1:Williams textbook of endocrinology, 11th ed.

2: Endocrinol Metab Clin North Am 2007;36(3):595-615

 Thyroxin (0.1 mg) 10 tab oral stat then 1 tab oral od

Goal is to replace the pool of hormone which has
largely become depleted1
The greatest survival occurs when thyroid hormone
is administered promptly and in large doses even to
the elderly and to those with heart disease1
Most patients become more alert 48 to 72 hours after
initiation of thyroid hormone2
1 : Med Clin North Am 1993;22(2):279-90 : ; 2: Crit Care Clin 2001;17(1):59-74

 Cortisol 23.7 g/dl

CPK
5,580 (0-190 U/L)
CKMB
277 (<25 U/L) = 5% (0-6%)
Troponin T 0.472 (<0.01 ng/ml)
( thyroxin)

Anemia
Hypercholesterolemia
High serum LDH
High serum CK & CKMB (up to 9,1602 & 32 %3 in
reported case)
High troponin T (up to 0.044)

1:Endocrinol Metab Clin North Am 2006;35(4):687-98 ; 2:Clin Chem 1996;42(9):1494-5 ;

3: Clin Chem 1987;33(4):622-4 ; 4: Int J Cardiol 2007;115(2):e83-5

D1

D2

Off
ETT

D4 D5 D6

 Off endotracheal tube ~50 hours

Day 4 BP 80/60
EKG ST depression in V3-6
CXR pulmonary congestion with RLL infiltration
CPK 1,917 CKMB 106 = 5.5% Troponin T 0.604
Echo: EF 40 %, no RWMA

 Infection
a normal temperature should be a clue to
infection
a low threshold for initiation of antibiotic

Aspiration pneumonitis
Cardiac or cerebrovascular disease
Endocrinol Metab Clin North Am 2006;35(4):687-98

 Augmentin 1.2 g iv q 8 hr
Enoxaparin 40 mg sc q 12 hr, ASA(V) 1 tab od
Atorvastatin 20 mg od
Day 7

 Day 14
CAG TVD with Lt main occlusion 65 %
CVT high risk
AntiTG 1:320 (<1:20)
Antimicrosome 1:400 (<1:100)

 73
CC : 1
PI : 18 3
2
PE : BT 36.5 RR 20 HR 80 BP 120/80 disorientation
thyroid gland -, no edema
BUN 88 Cr 3.9 Na 126 PG 120

FT4 0.04
TSH >100
Cortisol 46.9

pH 7.26
CO2 48.8
HCO3 22

D1 . D2 . D3 . D4 . D5 . D6 . D7
conscious not improve after HD

131I
10Can
year
PTA
Hyperthyroid
S/P
we early diagnose in this case?

 Undiagnosed or delayed diagnosis

Therapy should be initiated without awaiting the
results of confirmatory tests because a delay in
therapy worsens the prognosis

Williams textbook of endocrinology, 11th ed.

 Delaying endotracheal intubation and ventilatory

assistance
Not recognizing and promptly treating bacterial
infection
Overcorrect hyponatremia
Avoid fluid overload
Avoid rapid correction of hyponatremia
Med Clin North Am 1993;22(2):279-90

 Inadequate volume resuscitation

Vasopressors should be considered only if the patient
does not respond to judicious administration of
intravenous fluids

Misdiagnosis of drowsiness from narcotics as

myxedema coma
Increased sensitivity to anesthetic and sedative,
phenytoin, digoxin, warfarin

Myxedema coma can be prevented by

the early recognition and treatment
of hypothyroidism