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A Dyspnoeic Lady Author Dr Tang Chung Leung Dec 2013.

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Presentation on theme: "A Dyspnoeic Lady Author Dr Tang Chung Leung Dec 2013."— Presentation transcript:

1 A Dyspnoeic Lady Author Dr Tang Chung Leung Dec 2013

2 Case ▪ Triaged as Cat. 3 ▪ A 37 years old female ▪ C/O: dizziness and chest discomfort 1 day ago, severe back pain today, unable to walk ▪ BP 107/86 pulse 156/min ▪ Temperature and SaO2 not documented

3 History of Present Illness ▪ Sudden onset of back pain and limb pain in MTR for one day ▪ SOB for 2 weeks ▪ No chest pain ▪ No fever ▪ No cough Add your first bullet point here ▪ Add your second bullet point here ▪ Add your third bullet point here Past Medical History Tourist guide FU OLMH for thyroid problem Not taking any medication

4 Physical Examinations ▪ General conditions fair ▪ No pallor, jaundice, no LN palpable ▪ No neck mass noted ▪ Ankle edema noted ▪ No sweating ▪ Temperature not documented Respiratory:  Respiratory rate not documented  Bilateral basal crepitations CVS:  BP 107/86 mmHg, HR 156/min.  Distended neck veins  Heart sound normal, no murmur noted Abdomen:  soft

5 Investigations ▪ ECG – fast AF Rate ~ 150/min ▪ CXR: cardiomegaly, right pleural effusion ▪ Blood send for CBP, L/RFT, cardiac enzyme, thyroid function.

6 Summary of Clinical Findings ▪ Low back pain ▪ Fast AF ▪ Neck mass ▪ Borderline blood pressure reading ▪ Cardiomegaly/pleural effusion

7 Differential diagnoses ▪ ?Sepsis ▪ ?Heart failure/pericardial effusion/ tamponade ▪ ?Surgical emergency (Boerhaave ’ s Sx) ▪ ?Orthopaedics emergency ▪ ?Endocrine emergency (thyroid crisis) Provisional diagnoses ▪ Thyroid storm ▪ Atrial fibrillation ▪ Heart failure

8 Treatment ▪ High flow O2 ▪ Lasix 40mg ivi x2 ▪ Betaloc 5mg ivi x2 ▪ Carbimazole 20mg po ▪ Iodine (not available in AED) ▪ After treatment, ▪ BP 119/91 pulse 145/min ▪ She was admitted into medical ward. ▪ ? ICU

9 Progress ▪ D1 admission 21:20 ▪ On call medical MO, ▪ Found generalized hypotonia esp. lower limbs (grade 4/5) ▪ Right pleural effusion and back pain ▪ ? Cord compression ▪ ? Rupture esophagus ▪ ? Aortic dissection ▪ ? Any more

10 Progress ▪ Urgent CT thorax and x-ray LS spine ordered ▪ No aortic dissection, right pleural effusion ▪ X-ray LS spine were normal (assessed by orthopaedics colleagues) ▪ Orthopaedic opinion: ▪ Unlikely to be cord compression. ▪ Surgeon opinion: ▪ Unlikely ruptured esophagus (because patient was not in severe chest pain and not very septic) ▪ (? Sequence of events for Boerhaave ’ syndrome)

11 Progress ▪ D1 admission 23:10 ▪ Urgent echocardiogram: ▪ Impaired LVEF (45%), functional MR and TR ▪ D2 admission 14:15 ▪ Chest drain inserted with 1.5 litre pleural fluid drained. (transudative) Blood Results ▪ WBC 12.3 ▪ Hb = 10.9 ▪ Free T4 > 100 ▪ TSH < 0.01 ▪ ESR 1 ▪ CRP <1 ▪ CK. Troponin T - normal ▪ PTU 200mg QID added

12 Progress ▪ D3 admission 13:00 ▪ Patient developed shock ▪ BP 68/24 pulse 66 SaO2 91 ▪ Drowsy, shallow breathing and cold extremities ▪ GCS 3/15 ▪ No active bleeding and PR showed no malaena ▪ Intubated and transferred to ICU

13 Progress ▪ Persistent hypotension ▪ Multiple doses of volume expander and inotrope started ▪ Developed DIC ▪ INR up to 4.03 ▪ Multiple doses of FFP, platelet concentrate given ▪ Developed multiple organ failure and treated conservatively. ▪ D8 admission ▪ Persistent coma ▪ Bedside EEG showed depressed EEG activities ▪ D10 admission ▪ CT brain ▪ SAH, cerebral edema ▪ NS opinion: not for surgical intervention

14 Causes of death ▪ D17 admission: succumbed Causes ▪ Thyroid storm ▪ Septicemia ▪ Multiple organ failure ▪ Intracerebral hemorrhage

15 DISCUSSIONS

16 Terminology ▪ Hyperthyroidism: ▪ thyroid gland hyperfunction ▪ Increased thyroid hormone synthesis and release ▪ Thyrotoxicosis ▪ Increased metabolic and sympathetic nervous state as a result of elevated serum free thyroid hormone ▪ Thyroid storm ▪ Emergent multisystem disorder ▪ Extreme manifestation of thyrotoxicosis

17 Thyroid storm ▪ Thyroid storm is a rare complication( 1- 2 % hyperthyroidism patients) ▪ Precipitated by a physiologically stressful events such as trauma, myocardial infarction, pulmonary embolism, diabetic ketoacidosis, sepsis, partuition, surgery, excessive ingestion of iodine, and incorrect discontinuation of antithyroid drugs

18 Thyroid physiology ▪ Thyroid function is controlled by negative feedback loop that is regulated by circulating TSH and thyroid hormones (T4 and T3) ▪ Thyroid gland mainly produces T4 and smaller amount of T3 ▪ ≈80% of T3 is formed by conversion of T4 to T3 in periphery ▪ Over 99.5% of T4 and T3 are protein bound ▪ Bound hormone is metabolically inactive ▪ Serum free T3 (FT3) and T4(FT4) provide more valuable clinical information ▪ In thyrotoxicosis/ thyroid storm states, TSH concentration is very depressed with elevations of FT4 and FT3

19 Pathogenesis ▪ FT4 and FT3 are taken into the cells whereas T4 is converted into its active form ▪ Conversion of T4 to T3 is accomplished by deiodination in the outer ring of T4 ▪ Normally deiodination of T4 to T3 provides only 20% to 30% of T3 ▪ In thyrotoxic state, it can provide more than 50% ▪ Increase in amount of free thyroid hormone ▪ Increase in target cell beta- adrenergic receptor density ▪ Increase post receptor modifications in signaling pathways

20 Causes of Hyperthyroidism ▪ Circulating thyroid stimulators ▪ Graves’ disease ▪ Pituitary adenoma ▪ Choriocarcinoma ▪ Hyperemesis gravidarum ▪ Thyroid autonomy ▪ Toxic nodular goitre ▪ Toxic solitary adenoma ▪ Iodine-induced hyperthyroidism ▪ Exogenous thyroid hormone ▪ Excess ingestion of thyroid hormone ▪ Destruction of thyroid follicles (thyroiditis) ▪ Subacute thyroiditis ▪ postpartum ▪ Amiodarone induced ▪ Infectious ▪ Ectopic thyroid tissue ▪ Struma ovarii ▪ Metastatic follicular thyroid cancer

21 Symptoms ▪ CNS ▪ Emotional lability ▪ Anxiety ▪ Confusion ▪ GI ▪ Diarrhoea ▪ CVS ▪ Palpitations ▪ Chest pain ▪ Dyspnoea ▪ Ophthalmologic ▪ Diplopia ▪ Reproductive ▪ Oligomenorrhoea ▪ Loss of libido ▪ Dermatologic ▪ Hair loss ▪ Thyroid gland ▪ Neck fullness

22 Laboratory ▪ free T4 is elevated and TSH is decreased ▪ diagnosis must be made on the basis of the clinical examination

23 Thyroid storm- diagnostic criteria SCORE: ≥ 45: HIGHLY SUGGESTIVE OF THYROID STORM; 25-44: SUGGESTIVE OF IMPENDING STORM; BELOW 25: UNLIKELY TO REPRESENT THYROID STORM BURCH HB, WARTOFSKY L. LIFE-THREATENING THYROTOXICOSIS. THYROID STORM ENDOCRINOL META CLIN NORTH AM 1993;22(2): Diagnostic parametersScoring points Thermoregulatory dysfunction Temperature ≥ CNS effects Absent Mild (agitation) Moderate (delirium, psychosis, extreme lethargy) Severe (seizure, coma) GI-hepatic dysfunction Absent Moderate (diarrhoea, nausea/ vomiting, abdominal pain) Severe (unexplained jaundice) Cardiovascular dysfunction Tachycardia ≥ 140 Congestive heart failure Absent Mild (pedal edema) Moderate (bibasilar rales) Severe (pulmonary edema) Atrial fibrillation Absent Present Precipitating event Absent present

24 Management If untreated, thyroid storm may be fatal Thyroid storm often must be recognized and treated on clinical grounds

25 Management ▪ Multiple targets ▪ Inhibition of new hormone synthesis within thyroid gland ▪ Inhibition of thyroid hormone release ▪ Preventing conversion of T4 to T3 ▪ Controlling the adrenergic symptoms ▪ Supportive therapy ▪ Deal with underlying precipitants

26 Management ▪ Inhibition of new hormone production ▪ Propylthiouracil (extra effect of decreases T4 to T3 conversion) ▪ Carbimazole ▪ Inhibition of thyroid hormone release ▪ Lugol’s solution ▪ Potassium iodide/ SSKI ▪ (administer at least 1 hour after anti-thyroid medication)

27 Management ▪ Beta-adrenergic blockade ▪ Propranolol (extra effect of decrease T4 to T3 conversion) ▪ Atenolol (cardioselective) ▪ Metoprolol (cardioselective) ▪ Esmolol (intravenous) ▪ Supportive ▪ Acetaminophen (for hyperthermia) ▪ Glucocorticoids, e.g. hydrocortisone/ dexamethasone (decreases T4 to T3 conversion) ▪ External cooling: ice packs, cooling blankets ▪ IV fluid

28 Management ▪ Alternative therapies ▪ Lithium carbonate ▪ when anti-thyroid drugs or iodide therapy is contraindicated ▪ Decrease thyroid hormone secretion directly ▪ Potassium perchlorate ▪ in combination of anti-thyroid medication in treatment of Amiodarone induced thyrotoxicosis

29 Thank you


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