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A Dyspnoeic Lady

A Dyspnoeic Lady. Author Dr Tang Chung Leung Dec 2013. 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. History of Present Illness.

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A Dyspnoeic Lady

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

  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 • D1admission 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. 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 Symptoms

  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):263-77

  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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