And the answer to Case of the Month for July is…(...drumroll)…
Thanks to all who participated! This prize goes to Dr. Zeccola (only right answer, and an impressive calm excellence leading sim conference on Wednesday)
To recap, we have a 65 yo F who presents with:
- new onset Atrial fibrillation, currently in rapid ventricular response
- new onset congestive heart failure
- signs of infection (febrile/tachycardia as SIRSS criteria) without symptoms or signs indicating a specific source after negative cxr/ua/ct abd/pelvis.
- Abdominal pain out of proportion to exam with a negative CTA of the abdomen and pelvis
- Agitated, perhaps due to infection, pain or other etiology.
My initial concerns in this case were mesenteric ischemia, mesenteric ischemia, mesenteric ischemia, then pneumonia, intra-abdominal catastrophe such as appy, perf’d viscous, cholecystitis, cholangitis, UTI, or pyelonephritis. Â Once CT scan, xray, and Ua were negative for the above diagnosis, you need to start thinking of less common diagnosis – toxins, delirium tremens, hypothalamic stroke, exotic infections, pheochromocytoma, psychosis, or organophosphate poisoning to name a few.
Thyroid Storm
How Diagnose: Clinical Diagnosis! (how many of those do we have left?)
Burch and Wartofsky Scale can be found here and the score on it indicates the likelihood of thyroid storm. Notice that the scale includes agitation, abdominal pain, atrial fibrillation, and congestive heart failure! This patient’s score is 80 with a score >45 indicates a high likelihood of thyroid storm.
Technically, the patient should have a low TSH and a high T4, but this is not always the case.
Treatment
1. Supportive care: IV fluids, vitamins, tylenol, cooling. Though 25% have no known inciting cause, treat when found (DKA/HHS/ infection/PE/MI/ Eclampsia/Surgery).
2. Inhibit Thyroid Hormone release: PTU preferred over methimizole as PTU also inhibits T4 conversion to T3.
3. B-adrenergic Blocker: Propanolol first line. Can also use esmolol. Inhibits peripheral effects of thyroid hormone.
4. Prevent conversion of T4 to T3: hydrocortisone or Dexamethasone (also good as adrenal insufficiency common in thyroid storm)
5. Cholestyramine – decreases gut absorption of thyroid hormone. Has been shown to decrease thyroid hormone faster with ptu than when ptu is used alone.
6. Inhibit thyroid hormone production (at least 1 hour after step 2): Lugol solution, Potassium Iodide, or Iopanoic acid. If given before 1 hour, the iodine in these medications can lead to increased! thyroid hormone production.
Dispo: MICU
End game: radioactive iodine therapy or surgery
By Dr. Andrew Grock
References
Tintinalli’s Emergency medicine: A Comprehensive Study Guide, 7th edition
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1 Comment
Ian deSouza · July 11, 2014 at 12:24 pm
Comments on treatment:
If the patient really has acute pulmonary edema, one should consider intubation/ventilation and/or DC cardioversion. Also, in the setting of pulmonary edema, one should be wary of aggressive rate control as respiratory status may deteriorate (type I insufficiency). If beta-adrenergic antagonism is to be attempted, consider esmolol over propanolol as primary therapy (short duration of effect) in case of possible progression of cardiogenic shock.