Th Storm & Coma

8/17/2019 Th Storm & Coma

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หญงอาย 82 ป• 2 เดอน ปวดทอง LLQ ถายเหลวอาเจยน ไปรพ.

ตางจังหวัดพบโลหตจางและเกรดเลอดต า• 3 สัปดาห ไข ไมหนาวสั น ปวดทองไมดข น ให

ceftazidime• CT abdomen : bowel ileus, H/C no growth• เปล ยนเปน Sulperazon with metronidazole

refer มารพ.จฬาฯ


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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


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


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• TB 0.59 SGOT 20 SGPT 13 ALP 62Albumin 1.9 Globulin 3.0 g/L

• EKG NSR 97/min, no LVH


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1. Subacute fever with abdominal pain2. Bicytopenia

3. Aortic stenosis

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


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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 x3-4 d)• Thiamine 100 mg iv od•

Paracetamol(500 mg) 1 tab oral prn q 6 hr • ถาจะให beta blocker หรอ amiodarone กรณา notify


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Older patients may present with some atypicalsymptoms 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


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Graves’ disease• Solitary toxic adenoma• Toxic multinodular goiter •

Thyrotropin-

secreting pituitary adenoma• Thyroid carcinoma• Subacute thyroiditis• Struma ovarii/teratoma• hCG–secreting hydatidiform mole• Interferon alpha and Interleukin-2–induced thyrotoxicosis



15/53Endocrinol Metab Clin North Am 2006;35(4):663-86

Score ScoreTemperature(oF) (oC/5=(oF-32)/9)

99-99.9100-100.9

101-101.9

102-102.9

103-103.9

≥ 104

Central nervous system effects

Absent

Mild agitation

Delirium, psychosis, lethargy

Seizures, coma

GI-hepatic dysfunction Absent

Diarrhea, nausea/vomiting, abdominal

pain

Unexplained jaundice

510

15

20

25

30

0

10

20

30

0

10

20

Cardiovascular dysfunction

Tachycardia90–109

110–119

120–129

≥ 140

Congestive heart failure

Absent

pedal edema

bibasilar rales

pulmonary edema

Atrial fibrillation

AbsentPresent

Precipitating event

Absent

Present

5

10

15

25

0

5

10

15

010

0

10

< 25 is unlikely, 25-44 impending storm, ≥ 45 is highly suggestive of thyroid storm


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• Infection• Acute medical illness

•

Trauma• Surgery (thyroid &

nonthyroid)

• Iodine contrastadministration

•

Parturition• After 131I

• Thyrotoxicosis factitia

• Acute psychosis

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


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• 32-year old Singaporean man with bilateral pittingedema and atrial flutter was given oral propranolol 10mg. He became cardiovascular collapse 4 hr later

• 28-year -old Singaporean man with CHF for 1 weekwith atrial fibrillation. Both propranolol and digoxinwere commenced but he subsequently collapsed

• The Author suggest avoiding propranolol in patients

who may have long standing hyperthyroidism or CXRshowing cardiomegaly

Resuscitation 2007;73(3):485-90


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Miss diagnosis: apathetic thyrotoxicosis, sepsis± unconscious, heart failure, hepaticencephalopathy, 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


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Steroid avoidance• Cardiovascular collapse from β-blocker•

Rectal suppositories were not retained


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Clinically, it is prudent to assume that someone

with severe thyrotoxicosis has impending thyroidstorm, and to treat them aggressively, rather than

focus on specific definitions



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Ultimate stage of severe longstandinghypothyroidism

• Most patients are not comatose

• Diagnosis : marked stupor, confusion or coma ina patient with a history and physical finding of

hypothyroidism, esp. hypothermia

Rev Endocr Metab Disord 2003;4(2):137-41


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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 FT4decrement 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


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ชาย 79 ป • CC : เหน อย แนนหนาอก หายใจไมออก 2 วัน

• PI : 1 ป พดไมชัด ล นคับปาก นอนทั งวัน 2 สัปดาห เหน อย 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

Hx &

PE ?


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Lethargy, slowed mentation, poor memory,cognitive dysfunction, depression, or evenpsychosis

• Focal or generalized seizures



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• Dry, coarse, scalyskin

• Sparse or coarse hair • Hoarse voice

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Periorbital edema

• Nonpitting edema ofthe hands and feet

• Macroglossia• Delayed deep tendon

reflexes to areflexia• Paralytic ileus

Williams textbook of endocrinology, 11th ed. ; Endocrinol Metab Clin North Am 2006;35(4):687-98


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Hypoventilation• Moderate to profound hypothermia• Bradycardia, and reduced cardiac contractility

– Cardiomegaly from ventricular dilatation or pericardialeffusion

– Frank congestive heart failure is rare

• Hypotension because of decreased intravascularvolume



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• Hypothermia• Infections

• Cerebrovascular accidents

• Congestive heart failure

• Anesthetics

•

Sedatives, Narcotics• Amiodarone, Lithium

• Gastrointestinal bleeding• Trauma

• Metabolic disturbances:Hypoglycemia,Hyponatremia, Acidosis,Hypercalcemia, Hypoxemia,

Hypercapnia



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ชาย 79 ป • CC : เหน อย แนนหนาอก หายใจไมออก 2 วัน

• PI : 1 ป พดไมชัด ล นคับปาก นอนทั งวัน 2 สัปดาห เหน อย 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?


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• Admit ICU, EKG, UA, cortisol, NG dripWhat was missing from the order?


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Admitted to ICU and EKG monitoring• Assisted ventilation 24-48 hours

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External warming should be avoided• Frequent turning

• Prevention of aspiration

• Attention to fecal impaction and urinary retention

Williams textbook of endocrinology, 11th ed.


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• 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


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Na 112 K 4.2 Cl 78 HCO3 19 AG 15• Cr 1.7

Order?


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• PRC before thyroxin

• BW ~ 70-80 kg• Serum Na

↑ 8 mEq/L in6 hours

•

ได steroid 1 วันWhat was missing from the order?


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Asymptomatic mild hyponatremia (> 120 mEq/L)can be monitored without specific therapybecause it usually resolves with thyroxine

therapy

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


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Production of cortisol is reduced inhypothyroidism• Peripheral degradation of hormone is retarded• Excretion of cortisol metabolites in the urine is

reduce•

Overalleffect

is normal concentration of cortisolin plasma

The American Journal of The Medical Scinces 1972;264(6):433-43


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Hydrocortisone usually is given intravenously(50–100 mg every 6 to 8 hours for several days)1

• All patients should be given stress-dose steroidsfor the first 24 - 48 hours2

1:Williams textbook of endocrinology, 11th ed.2: Endocrinol Metab Clin North Am 2007;36(3):595-615


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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 hormoneis administered promptly and in large doses even tothe elderly and to those with heart disease1

• Most patients become more alert 48 to 72 hours afterinitiation of thyroid hormone2

1 : Med Clin North Am 1993;22(2):279-90 : ; 2: Crit Care Clin 2001;17(1):59-74


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Cortisol 23.7 g/dl

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CPK5

,580(

0-

190 U/L)CKMB 277 (


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Anemia• Hypercholesterolemia

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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


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D1 D2 D4 D5 D6Off

ETT


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Off endotracheal tube ~50 hours• Day 4 หอบเหน อย ไมเจบหนาอก 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


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Infection – a ‘‘normal’’ temperature should be a clue to

infection

– a low threshold for initiation of antibiotic• Aspiration pneumonitis

• Cardiac or cerebrovascular disease



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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


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Day 14• CAG TVD with Lt main occlusion 65 %

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CVT แนะนาไมผาตัดเพราะ high risk

• AntiTG 1:320 (


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หญง 73 ป• CC : สับสน 1 สัปดาห

• PI : 18 ป เบาหวาน 3 เดอน บวมหนา ทอง ขาสองขาง 2 เดอน ปวดทอง ทองผก ซมลง ทานไดนอย

• 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

pH 7.26FT4 0.04


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D1 . D2 . D3 . D4 . D5 . D6 . D7

p

CO2 48.8

HCO3 22

4

TSH >100

Cortisol 46.9

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

conscious not improve after HD


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Undiagnosed or delayed diagnosis• Therapy should be initiated without awaiting the

results of confirmatory tests because a delay intherapy worsens the prognosis

Williams textbook of endocrinology, 11th ed.


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Delaying endotracheal intubation and ventilatoryassistance

• Not recognizing and promptly treating bacterialinfection

• Overcorrect hyponatremia – Avoid fluid overload – Avoid rapid correction of hyponatremia

Med Clin North Am 1993;22(2):279-90


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Inadequate volume resuscitation – Vasopressors should be considered only if the patient

does not respond to judicious administration ofintravenous fluids

• Misdiagnosis of drowsiness from narcotics asmyxedema coma

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


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Myxedema coma can be prevented by

the early recognition and treatmentof hypothyroidism

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Th Storm & Coma

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