Thyroid Storm

PRESKAS IGDTHYROID STORM

Oleh: Mira Puspita

Primary Survey

• A : clear, paten• B : spontan, simetris, RR 32x/mnt, Sa02

97%• C : nadi reguler, teraba kuat, 130x/mnt, TD

150/100 mmHg, akral hangat, CRT<3’’• D : Alert• GDS : 157

Data Dasar

• Nama : Ny. S• Usia : 60 tahun• Alamat : Empang• Pekerjaan : IRT• Pembiayaan : Jamkesmas • Tanggal datang : 27 Maret 2014 pk. 17.20 WITA

• KU : Berdebar-debar yang semakin menghebat sejak 1 hari SMRS

Tatalaksana Awal

• Pasien ditempatkan di critical care (P1) • O2 nasal kanul 4 lpm• IVFD RL 500 cc guyur• EKG• Cek DL, GDS, Elektrolit

Secondary Survey

S:• Berdebar-debar yang semakin menghebat sejak 1 hari SMRS.

Sebelumnya mempunyai riwayat berdebar sejak 3 bulan SMRS. Terasa sesak sejak 1 hari SMRS.

• Lemah sejak 3 bulan terakhir• Mengaku mata menonjol dan sering berkeringat kurang lebih

2 bulan terakhir• Nafsu makan menurun, BB menurun 6 kg dlm 2 bln• Demam dan batuk berdahak sejak 2 hari SMRS• Diare sejak 2 hari SMRS, 4x/hari, air (+), ampas (+)• Tidak bisa tidur sejak 2 hari SMRS

S:• BAK dalam batas normal• Menopause (+) sejak 7 tahun yg lalu• Riwayat gondok sebelumnya (-)• Riwayat HT (-), DM (-), riw. Sakit Jantung (-),

Riw. Stroke, trauma, koma, kejang, operasi disangkal

• Riw. Keluarga: HT (-), DM (-)

Pemeriksaan Fisik • KU : Tampak sakit berat, terpasang NK,

E4V5M6, TD 142/111 mmHg, Nadi 130x/mnt reguler dan kuat, RR 36x/mnt, suhu 390C

• Kepala : deformitas (-), nyeri tekan (-), mukosa kering • Leher : Pembesaran KGB (-), tiroid teraba

membesar konsistensi kenyal, dapat digerakkan, tidak nyeri, bruit (-)

• Mata : konjungtiva pucat -/- , sklera ikterik -/- , RCL +/+, RCTL +/+, diameter pupil 3 mm, tampak exoptalmus +/+, Lid retraction +/+

• Jantung : S1-S2 reguler, murmur (-), gallop (-)

• Paru: – Simetris saat statis dan dinamis, retraksi sela iga (-)– Fremitus paru kanan=kiri– Batas paru dalam batas normal– Vesikuler +/+, wheezing -/-, rhonki -/-

• Abdomen : supel, datar, nyeri tekan (-), shifting dullness (-),turgor normal, Hati dan Limpa tidak membesar, BU (+)

Secondary Survey

• Ekstremitas : akral hangat, CRT < 3’’, sianosis (-), edema (-),tremor pada kedua tangan

Secondary Survey

HASIL LABORATORIUM

ELEKTROLIT HASIL NORMAL

Natrium 135,16 135,37 - 145,00 mmol/L

Kalium 3,56 3,48 – 5,50 mmol/L

Clorida 104,99 96,00 – 106,00 mmol/L

Calsium Ion 1,67 1,10 – 1,35 mmol/L

Darah Rutin HASIL NORMAL

Hb 15,5 13,2-17,3

Ht 34,2 40,0-52,0

Leukosit 13000 3600-11000

Trombosit 212.000 150.000-436.000

Granulosit 68,5 1,8-7,7

Limposit 24,2 25,0-40,0

Mid 15,9 0,0-14,0

Kesan : Leukositosis, Granulositosis, Hipercalsemia

HASIL EKG

• Irama : Sinus TakikardiLaju : 123x/mntAxis : NormoaxisGel.P : Durasi 0,08 s, tinggi 1 mm

Pmitral (-), P pulmonal (-) Interval PR : 0,12 s Gel.Q : Q patologis (-)

•Komplex QRS :–Durasi komplex QRS 0,12 s–R V5 + S V1 < 35 kk

•Segmen ST : isoelektrik, ST depresi (-), ST elevasi (-)•Gel. T : T inverted II, III, aVF , v2-v5•Interval QT : 0,28 s (memendek)•Gel. U : negatif

Kesan : irama sinus takikardi, normoaxis, tidak ada hipertrofi ventrikel kanan maupun kiri, terdapat gangguan iskemik pada inferior, anteroseptal + lateral, gangguan elektrolit hipercalcemia

USG

USG

• Lobus dextra : nodul hiperechoik• Lobus sinistra : nodul hipoechoik • Kesan : SMNT susp ganas

BURCH & WARTOFSKY CRITERIA FOR THYROID STORM

70

>45 highly suggestive of thyroid storm25-45 suggestive of thyrotoxic storm

<25 unlikely

Working Diagnosis

• THYROID STORM• DEHIDRATION• ISKEMIK MIOKARD

Tatalaksana

• IVFD RL 500 cc guyur 30 tpm• PTU 400 mg• Propanolol 10 mg • Inj. Dexametason 5 mg• Lugol drop 5gtt kosong• Rawat ICU

Follow Up ICU28/03/2014, j, 08.30• Keluhan : masih berdebar-debar,

mencret (+)• KU : lemah• Kes : CM• TD : 124/78, HR : 96x/m, T:37,5 CP/• O2 2-4 lpm• Inf.RL 20 tpm• Inj. Dexametason 3x1• PTU 3 x 100 mg• Propanolol 1x 10 mg• PCT 3x1 tab• Neodiaform 3x1• Obs TTV

28/03/2014, j, 08.30• Keluhan : masih berdebar-debar, mencret

(-)• KU : lemah• Kes : CM• TD : 162/95, HR : 92x/m, T:37 CP/• O2 2-4 lpm• Inf.RL 20 tpm• Inj. Dexametason 3x1• PTU 3 x 100 mg• Propanolol 1 x 10 mg• PCT 3x1 tab• Amlodipin ext 5 mg• Inj ondansentron 2 x 4 mg• Obs TTV

TINJAUAN PUSTAKATHYROID STORM

• Krisis Tiroid (Thyroid storm)– Suatu keadaan hipertiroid yang mengalami

eksaserbasi sehingga mengancam kehidupan yang ditandai dengan dekompensasi dari satu atau lebih sistem organ dengan keadaan status hipermetabolik.

Symptoms• General symptoms

– Fever– Profuse sweating– Poor feeding and weight loss– Respiratory distress– Fatigue (more common in older adolescents)

• GI symptoms– Nausea and vomiting– Diarrhea– Abdominal pain– Jaundice

• Neurologic symptoms– Anxiety – Altered behavior– Seizures, coma

Physical Finding

• Fever– Temperature consistently exceeds 38.5°C.

• Excessive sweating• Cardiovascular signs– Hypertension– Cardiac arrhythmia

• Neurologic signs– Agitation and confusion– Tremors, seizures

• Signs of thyrotoxicosis– Orbital signs– Goiter

Table Precipitants of Thyroid Storm

Systemic insult Cardiovascular insult

Infection Myocardial infarction

Trauma Cerebrovascular accidents

General surgery Pulmonary embolism

Hyperosmolar coma Obstetrics-related

Endocrinal insult Parturition

Diabetic ketoacidosis Eclampsia

Drug- or hormone-related Unknown etiology in up to 25% of cases

Withdrawal of thyroid medication

Iodine administration

Radioactive iodine theraphy

Ingestion of thyroid hormone

BURCH & WARTOFSKY CRITERIA FOR THYROID STORM

MANAGEMENT

• Treatment aims are as follows:

• 1. Supportive care• 2. Drug Therapy :– Inhibition of thyroid hormone release– Inhibition of new hormone production– Peripheral -adrenergic receptor blockade– Preventing peripheral conversion of T4 to T3

Supportive Care

•General: oxygen, cardiac monitoring.• Fever: external cooling; acetaminophen, 325–650 milligrams PO/PR every 4–6 h•Dehydration: IV fluids• Cardiac decompensation (atrial fibrillation, congestive heart failure): rate control and inotropic agent, diuretics, sympatholytics as required.

Drug Therapy

• Antitiroid– PTU (propylthiouracil) 400-600 mg stat PO,

• Iodine solution– Lugol’s iodine 5 drops PO ; must give 1-2 hours

post PTU therapy• Beta Blockers• Propanolol 20-40 mg q 4 h

• Dexametason– 2 mg iv

TERIMA KASIH

2. Inhibition of thyroid hormone release with thionamides PTU, a loading dose of 600–1000 milligrams given PO and followed by 200–250 milligrams every 4 h. Total daily dose should be given: 1200–1500 milligrams/d. Drug can be given via nasogastric tube or PR. (PTU is the preferred thionamide as it also blocks peripheral conversion of T4 to T3.) or Methimazole, 40 milligrams given PO as loading dose and followed by 25 milligrams every 4 h. Total daily dose should be given: 120 milligrams/d. If given PR, 40 milligrams should be crushed in aqueous solution.

3. Inhibition of new thyroid hormone production (at least 1 h after step 2) Lugol solution, 8–10 drops PO every 6–8 h. or Potassium iodide (SSKI), five drops PO every 6 hours. or IV iopanoic acid (Telepaque®), 1 gram every 8 h for first 24 h, then 500 milligrams twice a day.

or Ipodate (Oragrafin®), 0.5–3 grams/d PO (especially useful with thyroiditis or thyroid hormone overdose).

or Lithium carbonate (if allergic to iodine or agranulocytosis occurs with thionamides), 300 milligrams PO every 6 h (1200 milligrams/d) and subsequently to maintain serum lithium at 1 mEq/L.

4. -adrenergic receptor blockade Propranolol, IV in slow 1- to 2-milligram boluses, which may be repeated every 10 to 15 min until the desired effect is achieved. For less toxic patient, PO dose of 20 to 120 milligrams per dose or 160 to 320 milligrams/d in divided doses (contraindicated in bronchospastic disease and congestive heart failure). Treat congestive heart failure before starting propranolol (e.g., starting dobutamine).

or Esmolol, 500 micrograms/kg IV bolus, then 50–200 micrograms/kg/min maintenance (selective -adrenergic blocker).

or Reserpine, 2.5–5.0 milligrams IM every 4–6 h, preceded by 1-milligram test dose while monitoring blood pressure (use if -blocker contraindicated and congestive heart failure, hypotension, and cardiac shock not present, see the Alternative Treatments section).

or Guanethidine, 30–40 milligrams PO every 6 h (use if -blocker contraindicated and congestive heart failure, hypotension, and cardiac shock not present, see the Alternative Treatments section).

5. Preventing peripheral conversion of T4 to T3

Hydrocortisone, 100 milligrams IV initially, then 100 milligrams three times/d until stable (also for adrenal replacement due to hypermetabolism). or Dexamethasone, 2 milligrams IV every 6 h.6. Treat precipitating event All triggers of thyroid storm should be searched and treated accordingly (infection, myocardial infarct, diabetic ketoacidosis, etc.).7. Definitive therapy Radioactive iodine ablation therapy or surgery may be necessary.