Thyroid Disorders

Chapter

Abstract

Thyroid storm and myxedema coma are endocrine emergencies with high morbidity and mortality, where early recognition with a low index of suspicion and prompt treatment can significantly impact outcomes [1]. The diagnosis of thyroid storm is made clinically and cannot be based on laboratory abnormalities, and diagnostic criteria have been put forth by Burch and Wartofsky and by Akamizu et al. [2, 3]. Multidisciplinary care in a critical care setting is recommended, and identification of the precipitating cause and reversal or treatment of that cause should be sought if possible [1]. Medical treatment of thyroid storm involves understanding the pathophysiology underlying its development and then targeting all steps of thyroid hormone synthesis, release, and action in a specified order, along with supportive care [1]. Treatment should begin with thionamides (propylthiouracil/PTU preferred over methimazole), then iodine administration (potassium iodine or Lugol’s solution) or alternatively lithium, then cholestyramine to block the enterohepatic circulation of thyroid hormone, and beta-blockers (propranolol or esmolol), temperature regulation with cooling and antipyretics (Tylenol preferred over salicylates), intravenous fluid resuscitation for dehydration, and stress dose steroids (hydrocortisone) with vasopressors as needed. Therapeutic plasma exchange (TPE) or plasmapheresis can also be utilized. Finally, definitive therapy is surgery (subtotal or near-total thyroidectomy) or radioactive iodine ablation.

Myxedema coma is severe hypothyroidism, often with significant hypothermia, bradycardia, and mental status changes as substantial as a coma, often with a precipitating cause. Popoveniuc et al. [4] have proposed a diagnostic scoring system for myxedema coma. Medical treatment for myxedema coma involves thyroid hormone replacement (with T3 and/or T4), supportive care (warm ambient temperature and warming blankets, IV fluids including potentially hypertonic saline for hyponatremia, mechanical ventilation or other ventilation support, and hydrocortisone), and treatment of the precipitating cause and any other sequelae of myxedema coma including seizures. The mortality of both thyroid storm and myxedema coma has improved over the years with improvements in critical care.

Keywords

Enterohepatic circulation of thyroid hormone Graves’ disease Hyperthyroidism Myxedema coma Plasmapheresis Therapeutic plasma exchange Thionamides Thyroid storm Thyroiditis Thyrotoxicosis Thyrotoxic crisis Wolff-Chaikoff effect 

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Authors and Affiliations

  1. 1.General SurgeryRutgers Robert Wood Johnson Medical SchoolNew BrunswickUSA
  2. 2.Rutgers Robert Wood Johnson Medical SchoolNew BrunswickUSA
  3. 3.Division of General SurgeryRobert Wood Johnson University HospitalNew BrunswickUSA

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