CASE PRESENTATION

Suad Al-Sulimani

OUTLINE

Case presentation

Case discussion

Topic review

23 years old male

sudden onset of SOB & palpitation

1 day duration

Primary survey

A:patent

no secretion

Generally:

Anxious , Irritable , sweatyContious , orianted

A:patent

no secretion

Generally:AnxioushyperventilatingContious , orianted

B:

DyspnicRR:22/minspo2 100% in RAChest : clear

A:patent

no secretion

Generally

AnxioushyperventilatingContious , orianted

B:

DyspnicRR:22/minspo2 100% in RAChest : bilaterally clear

C:

Pr:140/min(regular , good volume)

bp164/90 mmhg

A:patent

no secretion

Generally:

AnxioushyperventilatingContious , orianted

B:

DyspnicRR:22/minspo2 98% in RAChest : clear

C:

Pr:140/min ( regular , good volume)

Bp 164/90mmhg

D:

Reflow:6.8Pupils: bilaterally reactive

GCS: 15/15

A:patent

no secretion

Generally:AnxioushyperventilatingContious , orianted

B:

DyspnicRR:22/minspo2 98% with 100% o2Chest : clear

C:

Pr:140/min( regular , good volume )

bp150/60

D:

Reflow:6.8

Pupils:bilaterally reactive

GCS: 15/15

E:No obvious external injuries or bleeding Temp:afebrile

HISTORY

= young male , unmarried , work as water tank driver

= after stressful event at home, was driving his car , suddenly has sob , palpitation , became dizzy

= stopped the car , call for help = associated chest pain :unspecific , left

sided chest , burning , with sweating

Since 3 mounths , have onn/off chest pain , mainly after stress , not related to excertions , associated with sweating & palpitation

No cough or fever No GI symptoms No h/o contact with sick person No recent travel. Never smoke or drink alcohol. Denying h/o drug intake No FH of sudden death or CAD

EXAMINATION:

Hyperventilating Not ecteric , no skin rash , not dehydrated ,

no neck stiffness Fundoscopy : no papilodema JVP:not raised, no pedal edema Chest:, clear CVS: normal s1s2, no added sounds Abdomen is soft, no hepatomegaly.

DIFFERENTIAL DIAGNOSIS

Cardiac :Arrhythmias ,ACS ,CardiomyopathyPericarditis Respiratory :Pulmonary embolism Endocrine : Hyperthyrodism ( thyroid

storm ) , Phyochromocytoma Drug overdose : sympethatomimatic ,

anticholenergic Psychological :Hyperventilation , anxiety

disorders

ECG

CHEST X-RAY

Trop T < .014, repeated Trop T <.014

ACTION TAKING Midazolam total of 13 mg ABG : Po2 118 , PH 7.4 , Pco2 22

Bedside Echo ( done by cardiologist ):Normal , good EF , no evidence of pericarditis

Hb is 14.7,hct:46.2,plt202, wbc:4.5,neutrophile 1.1,lymphocyte:2.5

Urea:3.8, creat:68, K: 4.3, Na:143

Salicylate level :normal TSH < .003 (.35-4.9 ) Free T4 42 .6 (8.2 – 22.6

) LFT : normal , CK : normal ,

bone profile WNR

Admitted in HiDe , monitored for 48 hrs

Remain tachycardia ,PR 128/min , high BP 180/70 , maintaining sat , c/o sweating

His BP controlled with IV Labetelol Started on Propranolol Carbimazol &

lugol’s iodenine solution 1 ml tid for 1 week

BP controlled , PR improved 100/min , 80/min 24-hour urine catecholamines and

metanephrines was done , came as normal

Discharged home after 4 days on Carbimazol &n Propranolol with f/u appointment in Endocrine clinic

THYROID STORM

THYROID STORM

The overall incidence of hyperthyroidism is estimated between 0.05% and 1.3%

Thyroid storm is a rare disorder. Approximately 1-2% of patients with hyperthyroidism progress to thyroid storm

Mortality approximately 10-20%, but it has been reported to be as high as 75% in hospitalized populations. Underlying precipitating illness may contribute to high mortality.

thyroid hormones in Pt with hyperthyrodism…

thyroid hormones in Pt with hyperthyrodism…

symptoms get worse

One major sign of thyroid storm that differentiates it from plain hyperthyroidism is a marked elevation of body temperature, which may be as high as 105-106 ºF a life-threatening emergency

THYROID STORM CAUSES

Untreated hyperthyrodism Infections, especially of the lung  Thyroid surgery in patients with overactive

thyroid gland Stopping medications given for

hyperthyroidism Too high of thyroid dose Treatment with radioactive iodine Pregnancy Heart attack or heart emergencies  Emotional stress 

THYROID STORM SYMPTOMS

Rapid heart beats Greatly increased body temperatur Chest pain Shortness of breath Anxiety and irritability Disorientation Increased sweating Weakness Heart failure

Fever ranges from 100.4-105.5.  The pulse rate may range between 120 and 200 beats per minute but has been reported as high as

300 . . . sweating so profuse  as to lead to dehydration from insensible fluid loss . . .

Medical Treatment

A complete evaluation to determine the cause of thyroid storm

Intravenous fluids and electrolytes Oxygen if needed  Fever control with antipyretics (fever-

reducing medications) and if needed cooling blankets

Intravenous corticosteroids such as hydrocortisone

DEFENITIVE TRATMENT

Medications to block the production of thyroid hormones, such as propylthiouracil (PTU) or methimazole

Iodide to block thyroid hormone release Block the action of thyroid hormones on the

cells by drugs called beta-blockers, such as propranolol (Inderal) 

Treatment of heart failure if present

Next Steps Following the start of treatment, careful

monitoring, usually in the intensive care unit, is necessary.

Following recovery from thyroid storm, options for definitive treatment are radioactive iodine or antithyroid medications; surgery is rarely needed.

Rescue PCI

Rescue PCI is reasonable for selected patients 75 years or older with ST elevation or LBBB or who develop shock within 36 hours of MI

It is reasonable to perform rescue PCI for patients with one or more of the following:

a. Hemodynamic or electrical instability

b. Persistent ischemic symptoms.