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By Saud Al-Sulimani
Citation preview
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.