Live Blog: Hyperthyroid Storm

Case: A 25 year old male presented to the Emergency Department with palpitations.

• A week ago, the patient experienced racing heart, diaphoresis that are progressive and constant. 
• Patient has:
• loose stools
• weight loss
• loss of appetite
• PMHx: 
• asthma
• is a smoker
• uses alcohol
• has history of drug use
• Family Hx: 
• Diabetes Mellitus
• Cardiovascular disease
• Arthritis
• Pertinent negatives: 
• drug use
• infection
• fever
• recent illness

Physical Exam:

• HR 150
• RR 20
• BP 91/50
• Temp 31.8°C 
• O2 sat 91%, patient was put on mask
• Pulmonary crackles on lung exam
• Chem 7 and CBC labs were normal
• Thyroid: markedly low TSH
• Cardiac EKG: a-fib
• Tox screen negative

Interventions and Results:

• Given IV fluids
• Given Propanolol (beta blocker) —> decrease in HR but slight increase in BP
• Iodide
• PTU/methimazole
• Decrease in O2 sat

Ddx: 

• Endocrine
• CNS/autonomic
• Cardiac

Take Home Points: 

• 25 year olds don’t normally get a-fib. 
• HR and BP together tells what the cardiac output is. 
• Giving fluid could help make the diagnosis of Overflow and Cardiogenic Shock because you could get high output heart failure from all the extra stimuli. 
• Presence of antibodies would help diagnose Grave's Disease. 
• Give iodine last because will make things worse if you haven’t blocked things downstream—> called the Wolff Chaikoff effect. 
• Thyroid toxicosis: 
• Elevated thyroid function
• Temperature nearly febrile
• Endocrine system: 
• Antibody caused increased TSH production. 
• Thyroid overproducing T4 and T3, which are binding to tissue and triggering feedback to inhibit TSH. 
• The ideal drug design would be to block conversion from T4 to T3. 
• PTU, meth, iodine stop this production

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