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EMERGENCY AND CRITICAL CARE IN THYROID STORM

HARMOKO (090100254)HEMA THIYAGU (090100408)ANISSA ZAMANI (090100376)

Pembimbing : dr. Dadik Wahyu Wijaya, Sp An

previously undiagnosed hyperthyroidism

Thyroid gland secretes 2 hormones :– Thyroxine (tetraiodothyronine or T4)– Triiodothyronine (T3)– Secretion ratio T4 to T3 is 15:1– Iodine is attached to tyrosine amino acid residues of thyroglobulin in the gland (organification)– Coupling of these residues then produces T4 & T3

Thyroid Physiology

Thyroid Physiology (cont.)

T4 & T3 released by the gland are bound & transported by serum proteins :–Thyroxine-Binding Globulin (TBG) : 75 %–Thyroxine-Binding Prealbumin (TBPA)–Albumin

The free (or unbound) hormone levels are the levels which are maintained constant by feedback & regulate thyroid function

Total measured serum T4 includes bound & unbound

Variations in Thyroxine Binding Proteins

Causes of increased TBG levels :–Pregnancy, estrogens, cirrhosis, hepatitis, porphyrias

Causes of decreased TBG levels :–Protein malnutrition, nephrotic syndrome, hepatic failure, androgenic steroids, high dose glucocorticoids

Free T4 (FT4) usually constant in the above conditions

Thyroid Hormone Action in the Tissues

T4 deiodonated in periphery to T3–This is 80 % of T3 produced

Other metabolite of T4 is reverse T3 (rT3) which is metabolically inactive

T3 enters cells & binds to group of nuclear receptors, then affects wide range of cellular metabolic functions

Thyroid hormone required for normal cell metabolism

Feedback Regulation of Thyroid Hormone Levels

Normal regulation requires intact hypothalamic-pituitary system

Hypothalamus secretes Thyrotropin-Releasing Hormone (TRH)

TRH then stimulates synthesis & release of thyrotropin (Thyroid Stimulating Hormone or TSH) by the anterior pituitary

TSH then stimulates the thyroid gland to uptake iodine, synthesize & release T4 & T3

T4 & T3 levels feedback to both hypothalamus & pituitary affecting TRH & TSH release

Feedback Regulation of Thyroid Hormone Levels

Thyroid Function Tests

Radioimmunoassay for T4 (T4RIA) is most useful single test of thyroid function–Normal levels 4 to 12 mcg / dl

Free thyroid homone difficult to measure directly, so "indirect" tests developed –T3 Resin Uptake (T3RU) measures amount of radioactive T3 unbound when added to patient's serum

–Reflects of sites available for binding T4 &T3–Is indirect measure of level of circulating T4–Normal is 25 to 35 %

Other Thyroid Function Tests

Free T4 Index (FT4I)–Correlates with level of Free T4–Is the product of T4RIA & T3RU

T3 radioimmunoassay (less useful)–Normal 75 to 195 ng / dl

Serum TSH–Normal is 0.3 to 5.0 mcU / ml

TRH Stimulation Test–Measures TSH response to TRH IV injection–Normal is increase in TSH to 30 mcU / ml

Clinical Interpretation of Thyroid Function Tests

T3RU :–Low in hypothyroidism & high TBG states–High in hyperthyroidism & low TBG states–T4RIA & the T3RU go in same direction with thyroid disease & in opposite directions with TBG level abnormalities

TSH–Elevated in primary hypothyroidism–If patient hypothyroid & TSH is low, then lesion is in hypothalamic-pituitary axis, and TRH Stimulation Test should be done

Directional Changes in Thyroid Function Tests

Clinical State

Total T4 T3RU FT4I Free T4 TSH

Euthyroid N N N N N

Hyper- thyroid

Hypothyroid

High TBG N N N

Low TBG N N N

Nonthyroid Illness N or N or N or N or

Medications Which May Cause "Euthyroid Hyperthyroxinemia"

Oral contraceptivesNarcotics (methadone, heroin)PerphenazineClofibrate5-flurouracilHeparinAmiodaroneIodine contrast agents

Disorders of Thyroid Hormone Excess

"Thyrotoxicosis" is the term for all disorders with increased levels of circulating thyroid hormones

"Hyperthyroidism" refers to disorders in which the thyroid gland secretes too much hormone

Radioactive iodine uptake test (RAUI) distinguishes hyperthyroidism from other forms of thyrotoxicosis

The Radioactive Iodine Uptake Test (RAIU)

Quantitates the fraction of a dose of radioiodine I-123 taken up by the thyroid gland within 24 hours

Normal is 5 to 30 %Elevated when thyroid gland is overstimulatedDecreased when thyroid gland is suppressed

(as by ectopic production of T4 or T3) Is decreased falsely by recent iodine load (as

from contrast computed tomography scan)

Graves Disease

Toxic multinodular goiter with hot nodule

Thyroid scans

Causes of Thyrotoxicosis with Elevated RAUI

Graves' DiseasePituitary tumor secreting excess TSHPituitary insensitivity to feedbackHydatidiform moleChoriocarcinomaTestis embryonal carcinomaToxic multinodular goiterToxic uninodular goiter

Causes of Thyrotoxicosis with Decreased RAUI

Acute autoimmune thyroiditis (may later lead to hypothyroidism)

Infectious thyroiditisPostpartum thyroiditisFactitious (taking PO excess thyroid

hormone)Metastatic thyroid cancerStruma ovarii (dermoid tumors or teratomas

of the ovary)

Medications Which Can Induce Hyperthyroidism

IodineAmiodaroneLithium

Features of Graves' Disease(Toxic Diffuse Goiter)

Most common cause of hyperthyroidism (70 to 85 % of all cases)

Caused by thyroid stimulating immunoglobulinsMainly in young adults ages 20 to 505 times more frequent in womenHalf of cases have infiltrative ophthalmopathy

with exopthalmos (not seen with other causes of hyperthyroidism)

5 % have pretibial myxedema

Ophthalmo- pathy associated with Graves Disease

Symptoms Suggestive of Thyrotoxicosis

Nervousness, restlessness,shortened attention span, emotional lability, difficulty sleeping

Increased appetiteWeight lossHeat intolerance, perhaps low feverDiaphoresisWeaknessMenstrual irregularities

Signs Suggestive of Thyrotoxicosis

Sinus tachycardia, PVC's, PAC's, atrial fibrillationTremor, hyperreflexia, muscle wastingWarm, erythematous, moist skinAlopecia, nail friability & separation from bedHyperventilationEyelid retraction, lid lag, persistent stareHyperactive bowel soundsWith Graves' : may have exopthalmos, tender

enlarged thyroid, & pretibial myxedema

Possible Complications of Thyrotoxicosis at Presentation

High output congestive heart failureDehydrationElectrolyte imbalance (from diarrhea)Corneal lesions from exopthalmosWorsening of preexistent angina

Thyroid StormDefinitions

"Exaggerated or florid state of thyrotoxicosis""Life threatening, sudden onset of thyroid

hyperactivity"May represent end stage of a continuum :

–Thyroid hyperactivity to thyrotoxicosis to thyrotoxic crisis to thyroid storm

"Probably reflects the addition of adrenergic hyperactivity, induced by a nonspecific stress, into the setting of untreated or undertreated hyperthyroidism"

THYROID STORM - ETIOLOGY

GRAVES DISEASE

INFECTION

TRAUMA SURGERY

THYROID STORM CLINICAL PRESENTATION

2 most important defining features :–High fever (usually over 40 degrees C)–Significantly abnormal mental statusƒ Agitation, confusion, psychosis, coma

May also exhibit :–Marked tachycardia–Vomiting, diarrhea–Jaundice (in 20 %)–Associated signs of Graves' disease

Thyroid StormPrecipitating Factors

Infection, especially pneumoniaCerebrovascular accidentAcute coronary syndrome, Congestive heart failurePulmonary embolusDiabetic ketoacidosisParturition / toxemiaMajor traumaSurgeryIodine 131 Rx or iodine contrast agentsRapid withdrawl of antithyroid medications

Thyroid StormDiagnosis

Burch and Wartofsky criteria

• temperature (99->104) 5-30points• mental status change (mild-severe) 10-30• cardiac dysfunction

tachycardia (90->140) 5-25 pointsCHF (mild-severe) 5-15 pointsA-fib 10 pointsprecipitating event 10 points>45 points –thyroid storm

Thyroid StormDifferential Diagnosis

Environmental heatstrokeCocaine, amphetamine, or phencyclidine

toxicityNeuroleptic malignant syndromeMeningitis or encephalitisIntracranial hemorrhageMalignant hyperthermiaFalciparum cerebral malaria

Progression of Neurologic Findings in Thyroid Storm

Emotional labilityRestlessnessHyperkinesisConfusionPsychosisLethargySomnolenceObtundationComa

Cardiovascular Findings in Thyroid Storm

Marked tachycardia–Sinus tach or atrial fibrillation

Increased myocardial irritability–PVC's, PAC's, first degree AV block

Wide pulse pressureApical systolic murmurLoud S1 and S2 valve soundsSome have high output CHF

Usual Indicated Initial Lab Studies for Thyroid Storm

Glucose (stat fingerstick because of altered mental status)

Pulse oximetry (+/- ABG)CBC, electrolytes, BUN, creatinineT4RIA, T3RU, TSH, +/- T3RIAUrinalysisLiver function testsSerum cortisol

Thyroid StormEmergent Rx

High flow O2Rapid cooling if markedly hyperthermic

–Ice packs, cooling blanket, mist / fans, nasogastric tube lavage, acetominophen (Salicylates contraindicated because cause peripheral deiodination to T3)

IV fluid bolus if dehydrated–May need inotropes instead if in CHF

Propranolol 1 mg doses or labetolol 10 to 20 mg doses IV & repeat doses as needed

Thyroid StormFurther Rx

IV diltiazem +/- digoxin for rate control for atrial fib

IV diuretics if in CHFIV hydrocortisone (or equivalent) 100 mgPropylthiouracil (PTU) 600 to 1200 mg PO

or by NGSodium iodide 1 gram IV one hour after the

PTUFind and treat the precipitating cause

Thyroid StormAdditional Optional Meds

Lithium carbonate 600 mg PO–Follow-on dose 300 mg PO tid

Colestipol (resin which binds T4 in the gut) 10 grams PO–Follow-on dose 10 grams PO tid

Consider sedatives such as benzodiazepines (but beta blockers are the mainstay of therapy)

Actions of Antithyroid Meds for Thyroid Storm Rx

PTU inhibits hormone synthesis by the thyroid gland & also inhibits T4 to T3 conversion peripherally (this is why it is preferred over methimizole which just acts at the thyroid)

Iodine inhibits secretion of T4 & T3 from the thyroid (it must be given AFTER synthesis block from PTU or else it may provide more substrate for gland hormone synthesis)

Lithium can be used in patients alergic to iodine but can cause relapse when stopped

Follow-on Doses of Meds for Thyroid Storm

PTU 100 to 300 mg PO tid–Monitor for later agranulocytosis or liver dysfunction–Or Methimizole 20 mg PO tid to qid

Sodium iodide 500 mg IV q 12 hours–Or SSKI 5 to 20 gtts PO tid

50 to 100 mg hydrocortisone IV daily till stable, then wean as appropriate

Propranolol or labetolol or metoprolol (same daily doses as for hypertension)

Additional Rx for Thyroid Storm Not Responding to Initial Rx

Plasma exchange or plasmapheresisPeritoneal dialysis or charcoal

hemoperfusionEmergency surgery for partial or total

thyroidectomy

ANASTHESIA ASPECTS

Perioperative :• History taking and physical examination• Relative euthyroid before elective surgery• Benzodiazepine drug of choice for sedation• Quick preparation for emergent case

ANASTHESIA ASPECTS

Intraoperative :• Monitoring of hemodynamic and temperature• Avoid sympathetic stimulation drugs eg. Ketamine, pancuronium, adrenergic agonist• High dose thiopental has anti thyroid efect• Deep anesthesia sedation for preventing sympathetic stimulation

ANASTHESIA ASPECTS

Postoperative :• Thyroid storm onset 6-24 hours after surgery

Pr, 35 tahun,56 kg• KU : benjolan di leher • Telaah :⁻ Hal ini dialami pasien ± 1 tahun ini, awalnya benjolan kecil, lama

kelamaan makin membesar. Demam (+) dirasakan os ± 4 hari ini bersifat naik turun dan naik turun dengan pemakaian obat penurun panas.

⁻ Riwayat penurunan berat badan (+), ± 5 kg dalam 6 bulan ini, selera makan berkurang, os lebih suka udara dingin

⁻ Os juga lebih sering berkeringat terutama di telapak tangan, jantung sering berdebar-debar. Os juga merasa matanya makin membesar.

⁻ Riwayat keluar darah dari kemaluan (+), mual (+), muntah (+)• RPT : tidak jelas• RPO : tidak jelas

Primary Survey• A (Airway) : Airway Clear,

Gurgling/Snoring/Crowing : - /- /-• B (Breathing) : RR: 24x/menit, Suara Pernafasan :

Vesikuler, Suara Tambahan : -, Terpasang Nasal kanul dengan Oksigen 2 lpm.

• C (Circulation) : Terpasang IV line, dilakukan pemberian RL 20 gtt/i, Frekuensi Nadi 80 x/i, t/v kuat dan cukup, TD : 130/80 mmHg, Akral teraba hangat, merah, dan kering.

• D (Disability) : GCS 15, Sens: CM, Pupil Isokor diameter 3/3 mm, Refleks Cahaya +/+

• E (Exposure) : abdomen teraba soepel, ttb, peristaltik (+) N. Tampak benjolan pada leher.

Pemeriksaan Fisik • B1 (Breathing) : Airway clear, gurgling/snoring/crowing : - /- /- ,

SP : vesikuler, ST : -, RR : 24 x/i, SpO2 99%, Riwayat sesak/ asma / batuk / alergi (-), retraksi iga

(-), retraksi sternum (-). • B2 (Blood) : Akral merah/hangat/kering, HR : 80 x/i, t/v :

cukup, TD : 120/80 mmHg. T: 37.3oC• B3 (Brain) : Sensorium : Compos Mentis, GCS : 15

(E4V5M6), Pupil Isokor 3/3 mm, RC +/+• B4 (Bladder) : kateter (-), UOP : (+) sulit dinilai. • B5 (Bowel) : abdomen: soepel, peristaltik (+) N.• B6 (Bone) : Fraktur (-), edema (-) •

Pemeriksaan Lab tanggal 22/01/2014

Pemeriksaan Hasil

Hb 13.0 g/Dl

Ht 36.40

Leukosit 5.58 / mm3

Trombosit 159.000 / mm3

Natrium 136 mEq/L

Kalium 4,6 mEq/L

Klorida 104 mEq/L

Ureum 15,70

Kreatinin 0,20

Enzim Jantung CK-MB 52

Tatalaksana di IGD

• Bed rest • Diet MB • IVFD RL 20 gtt/i makro • Inj. Ranitidine 50 mg/12 jam• Propanolol 2 x 10 mg• PCT 3 x 500 mg

FOLLOW UP

Tanggal 6/02/2014O : A : P : R :B1 : airway clear, RR 28 x/i, SP : vesikuler, ST : -, S/C/G: -/-/-B2 : akral : H/M/K, TD : 85/60 mmHg, HR : 130 x/i, t/v : kuat/cukup,T:38.6CB3 : sens : compos mentis, pupil isokor ø 3mm, RC +/+B4 : kateter : (+) terpasang, UOP : 100 ccB5 : abdomen : soepel, peristaltic (+)B6 : oedem (-)

Thyroid storm + post SVT dengan hemodinamik stabil + pulmonary hypertension

- Bed rest head up 30º- O2 nasal kanul 2 l/i.- IVFD NaCl 0.9% 30 gtt/i- Inj Ranitidine 1 amp/12 jam/IV- PTU 200 mg/4 jam/oral - Propanolol 80 mg/8jam/oral- Methylclopramide 125 mg/8jam/IVPCT k/p 4 x 1 tab

- Cek darah lengkap- AGDA- Elektrolit- KGD- HST- T3, T4, TSH- Albumin

Hasil lab tanggal 6/02/2014Pemeriksaan Hasil

Hb 11.26 g/dL

Ht 23.50 %

Leukosit 8240 / mm3


PT 16.9 (12.8)

aPTT 30.3 (32,7)

TT 18.0 (16.2)

INR 1.36

Natrium 135 mEq/L

Kalium 2.8 mEq/L

Klorida 103 mEq/L

Ureum 16.0 mg/dL

Kreatinin 0.23 mg/dL

AGDA (NRM 5lpm, FiO2 60%)

pH 7.564

pCO2 23.5 mmHg

pO2 168.5 mmHg

HCO3 20.7 mmHg

Total CO2 21.5 mmol/L

Base Excess -0.7 mmol/L

SaO2 99.6 %

Tanggal 7/02/2014O : A : P :B1 : airway clear, RR 20 x/i, SP : vesikuler, ST : -, S/C/G: -/-/-B2 : akral : H/M/K, TD : 148/86 mmHg, HR : 114 x/i, t/v : kuat/cukup,T:37.6CB3 : sens : apatis, pupil : isokor ø 3mm, RC +/+B4 : kateter : (+) terpasang, UOP : 50 cc/jam, warna : kurang jernihB5 : abdomen : soepel, peristaltik (+) meningkat, mual (-), muntah (-) B6 : oedem (-)

Thyroid storm + post SVT dengan hemodinamik stabil + pulmonal hypertension

- Bed rest head up 30º- Diet SV 1500 kkal + 50 g protein- O2 nasal kanul 2 l/i.- IVFD NaCl 0.9% 30 gtt/i- Inj Ranitidine 1 amp/12 jam/IV- Inj Metoclopramide 10 mg k/p- PTU 6 x 200 mg - Propanolol 2 x 80 mg- Inj Methylprednisolone 125 mg/8 jam

- Paracetamol 500 mg tab k/p- Glaucon tab 3 x 1- 3 hari

Tanggal 8/02/2014 – 10/02/2014O : A : P :B1 : airway clear, RR 24 x/i, SP : vesikuler, ST : -, S/C/G: -/-/-B2 : akral : H/M/K, TD : 88/76 mmHg, HR : 113 x/i, t/v : kuat/cukup,T: 38.4CB3 : sens : apatis, pupil : isokor ø 3mm, RC +/+B4 : kateter : (+) terpasang, UOP : 60 cc/jam, warna : kuning jernihB5 : abdomen : soepel, peristaltik (+) NB6 : oedem (-)

Thyroid storm + post SVT dengan hemodinamik stabil + pulmonal hypertension

- Bed rest head up 30º- Diet SV 1500 kkal + 50 g protein- O2 nasal kanul 2 l/i.- IVFD NaCl 0.9% 30 gtt/i- Inj Ranitidine 1 amp/12 jam/IV- Inj Metoclopramide 10 mg k/p- PTU 6 x 200 mg - Propanolol 2 x 80 mg- Inj Methylprednisolone 125 mg/8 jam

- Paracetamol 500 mg tab k/p- Glaucon tab 3 x 1 (H3)

Hasil lab tanggal 10/02/2014Pemeriksaan Hasil

Hb 11.00 g/dL

Ht 32.10 %

Leukosit 7430 / mm3


Natrium 143 mEq/L

Kalium 3.3 mEq/L

Klorida 112 mEq/L


pH 7.531

pCO2 17.3 mmHg

pO2 188.3 mmHg

HCO3 14.2 mmHg



SaO2 99.7 %

Tanggal 11/02/2014O : A : P :B1 : airway clear, RR 24 x/i, SP : vesikuler, ST : -, S/C/G: -/-/-B2 : akral : H/M/K, TD : 88/76 mmHg, HR : 113 x/i, t/v : kuat/cukup, T:38.0CB3 : sens : apatis, pupil : isokor ø 3mm, RC +/+B4 : kateter : (+) terpasang, UOP : 60 cc/jam, warna : kuning jernihB5 : abdomen : soepel, peristaltik (+) NB6 : oedem (-)

Thyroid storm + post svt dengan hemodinamik stabil + pulmonal hypertension

- Bed rest head up 30º- Diet SV 1500 kkal + 50 g protein- O2 nasal kanul 2 l/i.- IVFD NaCl 0.9% 30 gtt/i- Inj Ranitidine 1 amp/12 jam/IV- Inj Metoclopramide 10 mg k/p- PTU 6 x 200 mg - Propanolol 2 x 80 mg- Paracetamol 500 mg tab k/p

- Glaucon tab 3 x 1 (H2)- Pemasangan CVC

Tanggal 12/02/2014O : A : P :B1 : airway clear, RR 36 x/i, SP : vesikuler, ST : -, S/C/G: -/-/-B2 : akral : H/M/K, TD : 120/66 mmHg, HR : 98 x/i, t/v : kuat/cukup,T: 37.2CB3 : sens : delerium, pupil : isokor ø 3mm, RC +/+B4 : kateter : (+) terpasang, UOP : 100 cc/jam, warna : kuning jernihB5 : abdomen : soepel, peristaltik (+) NB6 : oedem (-)

Thyroid storm + post svt dengan hemodinamik stabil + pulmonal hypertension

- Bed rest head up 30º- Diet SV 1500 kkal + 50 g protein- O2 via masker 6 - 8 l/i.- IVFD NaCl 0.9% 20 gtt/i- Aminofusin 7 gtt/I - Inj Ranitidine 1 amp/12 jam/IV- Inj Metoclopramide 1 amp k/p- PTU 4 x 800 mg - Propanolol 3 x 100 mg

- Paracetamol 500 mg tab k/p- Glaucon tab 3 x 1

Hasil Laboratarium Tanggal (12/02/2014)

Pemeriksaan Hasil

Natrium 146 mEq/L

Kalium 2.6 mEq/L

Klorida 123 mEq/L


pH 7.473

pCO2 23.1 mmHg

pO2 127.9 mmHg

HCO3 16.6 mmHg



SaO2 98.7 %

Tanggal 13/02/2014O : A : P :B1 : airway clear, RR 28 x/i, SP : vesikuler, ST : -, S/C/G: -/-/-B2 : akral : H/M/K, TD : 115/75 mmHg, HR : 130 x/i, t/v : kuat/cukup, T:38.5CB3 : sens : apatis, pupil : isokor ø 3mm, RC +/+B4 : kateter : (+) terpasang, UOP : 50 cc/jam, warna : kuning jernihB5 : abdomen : soepel, peristaltik (+) NB6 : oedem (-)

Thyroid Storm + SVT dengan hemodinamik stabil + pulmonal hypertension

- Bed rest head up 30º- Diet SV 1500 kkal + 50 g protein- O2 via masker 6 - 8 l/i.- IVFD NaCl 0.9% 20 gtt/i- Aminofusin 7 gtt/I - Inj Ranitidine 50 mg/12 jam/IV- Inj Metoclopramide 1 amp k/p- PTU 4 x 200 mg - Propanolol 3 x 100 mg

- Glaucon tab 3 x 1

Hasil Laboratarium Tanggal (13/02/2014)Pemeriksaan Hasil

Natrium 157 mEq/L

Kalium 3.7 mEq/L

Klorida 131 mEq/L


pH 7.386

pCO2 33.8 mmHg

pO2 87.8 mmHg

HCO3 19.8 mmHg



SaO2 96.2 %

Immunoserologi

T3 total 0.48 ng/mL

T4 total 4.47 µg/mL

TSH 0.005 µg/mL

Tanggal 14/02/2014O : A : P :B1 : airway clear, RR 32 x/i, SP : vesikuler, ST : -, S/C/G: -/-/-B2 : akral : H/M/K, TD : 82/57 mmHg, HR : 112 x/i, t/v : cukup, T : 38.7 CB3 : sens : delerium, pupil : isokor ø 3mm, RC +/+B4 : kateter : (+) terpasang, UOP : 20 cc/jam, warna : kuning jernihB5 : abdomen : soepel, peristaltik (+) NB6 : oedem (-)

Thyroid Storm + SVT dengan hemodinamik stabil + pulmonal hypertension

- Bed rest head up 30º- Diet SV 1550 kkal + 50 g protein- O2 via masker 6 - 8 l/i.- IVFD NaCl 0.9% 20 gtt/i- Aminofusin L600 7 gtt/i- Inj Ranitidine 50 mg/12 jam/IV- Inj Metoclopramide 1 amp k/p- PTU 4 x 200 mg - Propanolol 3 x 100 mg

- Glaucon tab 3 x 1 - Meropanem 1gr/12jam/IV

Tanggal 15/02/2014O : A : P : R :B1 : airway clear, RR 28 x/i, SP : vesikuler, ST : -, S/C/G: -/-/-B2 : akral : H/M/K, TD : 104/48 mmHg, HR : 143 x/i, t/v : cukup, T : 39.7 CB3 : sens : delerium, pupil : isokor ø 3mm, RC +/+B4 : kateter : (+) terpasang, UOP : 20 cc/jam, warna : kuning jernihB5 : abdomen : soepel, peristaltik (+) NB6 : oedem (-)

Thyroid Storm + SVT dengan hemodinamik stabil

- Bed rest head up 30º- Diet SV 1550 kkal + 50 g protein- O2 via masker 6 - 8 l/i.- IVFD NaCl 0.9% 20 gtt/i- IVFD Aminofusin L600 7 gtt/i- Inj Ranitidine 50 mg/12 jam/IV- PTU 4 x 200 mg - Propanolol 3 x 100 mg- Inj Methylprednisolon 125 mg/8 jam/IV - Glaucon tab 3 x 1 - Meropanem 1gr/12jam/IV

- Cek darah lengkap - Elektrolit- Thermoregulasi- Balance cairan

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