download file
TRANSCRIPT
Thyroid Storm in Pregnancy
Janna HoffmanAbra Berg
John Vozenilek, MDEvanston Northwestern Healthcare
Revision 1.0
Date: January 11, 2006
Case Outline.........................................................................................................................2I. Title: Thyroid Storm...............................................................................................2II. Target Audience:.....................................................................................................2III. Brief Case Summary............................................................................................2IV. Learning Objectives or Assessment Objectives..................................................2
A. Primary................................................................................................................2B. Secondary............................................................................................................2C. Critical actions checklist......................................................................................3
V. Environment............................................................................................................3VI. Actors...................................................................................................................3VII. Case Narrative.....................................................................................................4
Opening Information...................................................................................................4Physical Assessment with reveal:................................................................................4Non-simulator-based findings:....................................................................................4Scenario Background.................................................Error! Bookmark not defined.Scenario conditions initially........................................................................................4Scenario branch points.................................................................................................4
VIII. Debriefing Plan....................................................................................................5IX. Pilot Testing and Revisions.................................................................................5X. Authors and their affiliations:..................................................................................5
Instructors Notes..................................................................................................................6Use of BetaBlockers....................................................................................................6Use of PTU..................................................................................................................6
Sim Jockey Notes..............................................................................................................10Sim Jockey Tasks..............................................................................................................11Triage Notes.......................................................................................................................12References:........................................................................................................................19
Case Outline
I. Title: Thyroid Storm
Links to Model Curriculum for Emergency Medicine Resident Training: [1]
Develop knowledge of the etiologies, manifestations, and treatment of endocrine and metabolic disorders.
Demonstrate understanding of the common endocrine abnormalities, especially regarding presentation, initial evaluation and management, and disposition.
Links to 2003 Model of the Clinical Practice of Emergency Medicine [2, 3] Section 5.8
II. Target Audience: Medical Students Residents
III. Brief Case Summary Key words: endocrine disorder, thyrotoxicosis, hyperthyroidismAge: 29Gender: F
Overview: 29 year old woman with palpitation, sweating, tremor, anxiety, hyperactivity Initially symptomatic, if untreated, progresses to moderate congestive heart
failure Pulmonary Edema progresses to hypoxemia and cardiac instability if untreated
IV. Learning Objectives or Assessment ObjectivesA. Primary
Recognition of signs and symptoms of thyrotoxicosis Understand the management of patients with hyperthyroidism Appropriate Consultation
B. Secondary Classification of Thyrotoxicosis Understand the possible manifestations of hyperthyroidism Understand Risk factors
C. Critical actions checklist
Done Critical Action
Telemetry Monitoring ECG Thyroid examination1
Obtains TSH level Focused ROS appetite and weight changes Administers anti- thyroid medications Administers Beta- blocker therapy Endocrine consultation
V. EnvironmentSimulation Room as:
Emergency Department Critical care area
High Fidelity Patient Simulator Female No special moulage
Props: (airway equipment and code blue cart is assumed) Defibrillator IV line(s) Radiology
o CXRo CXR Intubated
Mock drugso Induction agentso Paralyticso IV Beta blockero IV PTU
VI. Actors Nurse
o confederate, obedient, not helpful Husband, other residents, other students, actors
o agrees with everything the wife says Consultant, other residents, other students, actors
o on phone – endocrinologist
1 This requires vocalization of the findings or some other ruse. The action might be omitted to alleviate the bias created naturally when performing HiFiSim
VII. Case Narrative Opening Information The patient is a young, otherwise healthy woman accompanied by her husband with a history of Graves Disease, diagnosed three months prior. The husband has brought her into the Emergency Department from home due to what he thinks is a “severe panic attack.” The patient is visibly jittery, crying, upset. She reports a lack of sleep. She does appear extremely anxious.
The patient has become pregnant and has not as yet had her first prenatal visit. She has been non-complaint with her medication methimazole, due to her concerns over the medication’s effect on her pregnancy.
A variation is offered for higher level trainees: No prior known history. No medications. The patient is a primary presentation of Graves disease and thyroid storm.
Physical Assessment with reveal: Tachycardia Atrial Fibrillation (irregular rapid pulses) Hypertension Rales
Non-simulator-based findings: Anxiety (voice) nurse also continuously reporting to the doctor that she is “so
anxious” and can’t she have something for the anxiety Picture of lid lag (see supplement) Tremor (nurse prompt)
Scenario conditions initially1. History patient gives: been nervous, etc. for the past week, with
symptoms worsening2. Patients initial exam: febrile, agitated, diarrhea , 3. Patients physiology: sinus tachychardic, soft and smooth skin
Scenario branch points1. Discussion with patient reveals that she has not been overly
concerned about her Grave’s disease, she only came to the hospital because she is trying to get pregnant and doesn’t want to be sick, doesn’t take her medicine because she thinks it will decrease her chances of getting pregnant
2. CT chest reveals thickened left ventricle3. Eye exam reveals no hyperthyroid manifestations in eyes4. If untreated with beta blockers (symptoms) and medicine (more
potent antithyroid drug: propylthiouracil (every 6 hours), leads to congestive heart failure
VIII. Debriefing Plan Individual
Group Instructors Notes are provided as debriefing materials. These notes provide
stimulus for question and answer sessions post-case and allow instructors to standardize their educational efforts related to the case.
Performance expectations, anticipated management mistakeso Insulin-euglycemic clamp therapy is not commonly offered by the
managing team o Whole Bowel Irrigation is not commonly offered by the managing team o Selected of RSI induction agent would be likely to cause severe
hypotension
IX. Pilot Testing and Revisions Numbers of participants
o This case has been run for emergency medicine residents and internal medicine residents in a small group setting
o One team of junior [primary participant] and senior [backup] residents manage the case
o The peer group typically consists of approximately 8 residents who watch the case and participate in debriefing
X. Authors and their affiliations:Janna HoffmanDivision of Emergency MedicineEvanston Northwestern Healthcare
Abra BergDivision of Emergency MedicineEvanston Northwestern Healthcare
John Vozenilek, MD FACEPAssistant Professor, Emergency Medicine, Feinberg School of Medicine, Northwestern UniversityDivision of Emergency MedicineEvanston Northwestern [email protected]
Instructors Notesuse of radioactive iodine is contraindicated, thyroid surgery rarely is recommended.[4]
Use of Beta-Blockers Indicated in the treatment of thyrotoxicosis. Complications:
intrauterine growth retardation, prolonged labor, neonatal bradycardia, hypotension, hypoglycemia, prolonged hyperbilirubinemia, evaluate the risk-to-benefit analysis [4]
Consider: Esmolol (cardioselective) Metoprolol Atenolol Propranolol
Use of PTUPregnancy is a “contraindication,” in routine conditions but PTU is felt to be the safer agent (compared with methimazole) and necessary in treating thyrotoxicosis[4]
Burch and Wartofsky Predictive Clinical Scale for Thyroid StormParameter taken into consideration Scoring PointsThermoregulatory dysfunctionTemperature (Oral, ºF)
99-99.9 5100-100.9 10101-101.9 15102-102.9 20103-103.9 25>104 30
CNS EffectsAbsent 0Mild (agitation) 10Moderate (delirium, psychosis, extreme lethargy)
20
Severe (seizures, coma) 30GI-hepatic dysfunction
Absent 0Moderate (diarrhea, nausea, vomiting, abdominal pain)
10
Severe (unexplained jaundice) 20Tachycardia (beats/min)
99-109 5110-119 10120-129 15130-139 20>140 25
Congestive Cardiac FailureAbsent 0Mild (pedal edema) 5Moderate (bibasal rales) 10Severe (pulmonary edema) 15
Atrial FibrillationAbsent 0Present 10
Precipitating EventsAbsent 0Present 10
≥45: highly suggestive of thyroid storm25-44: suggestive of impending storm
<25: unlikely to represent thyroid stormTietgens ST, Leinung MC. Thyroid Storm. Med Clin North Am 1995, 79:169-184.
Sim Jockey NotesAge 29Sex F
Current History Meds (dose)
CC:sweaty, tremor, anxiety, palpitations, hyperactive methimazole
(once daily but doesn’t take it)
Onset 10 days agoDuration 10 daysLocation n/aCharacter n/aQuality intermittent
Aggravation
Talking about her Graves disease or upcoming pregnancy
Alleviation NoneRadiation n/a
Had before?/Recurrence?More minor, before her Graves diagnosis Allergies
Patient Thinks/Concerns Will I get pregnant? NoneSeverity (number) 8/10 (she’s anxious!)
Timeline Past Medical
3 months agoDiagnosed with Graves disease Graves Disease (3 months)
10 days ago Symptoms worsenPast Surgical
Review of Systems None(positive only) Diarrhea, febrile, smooth skin
tachycardicSocial Hx
Married advertising executiveTobacco noneETOH sociallyOther no
Sim Jockey TasksOverview: Febrile, nervous, palpitations, hyperactive, tremor
Successful treatment will improve or delay progression below"Treatment" BetaBlockade, PTU
Time BP HR RR Rhythm POX
0 : 00 180/110 170 30 ST 94 RR up to 30 Shunt ~(.2)0 : 30 Atrial Fibrillation1 : 00 HR 1.61 : 30 Phenylephrine gttts @ 10-20 2 : 002 : 303 : 003 : 304 : 00 180/110 170 40 ST 90% Begin rales Shunt ~(.3)4 : 30 RR up to 405 : 005 : 306 : 006 : 307 : 00 180/110 170 40 ST 89% Shunt .57 : 308 : 008 : 30 60/p 180 40 VT VT with pulse9 : 009 : 30
10 : 0010 : 3011 : 00 0 0 0 VF VF11 : 30
Triage Notes
Chief Complaint Anxiety Attack
Age 29Gender F
VitalsHR 170RR 30BP 180/110
Temp 99.5Pulse Ox 94
DEPARTMENT OF PATHOLOGY AND LABORATORY MEDICINE
=======================================================================
=======================================================================
COMPLETE BLOOD COUNT
WBC 8.6RBC 5.0HEMOGLOBIN 15.6HCT 46.4MCV 91.2MCH 30.6MCHC 33.5RDW 14.5PLATELET COUNT 241/0
AUTOMATED DIFFERENTIAL
LYMPH% 35.8MONO% 8.2NEUT% 50.5EOSIN% 3.0BASO% 1.3
FOR RESULTS AND INFORMATION CALL 847-570-4223
CSTAR
2650 RIDGE AVE ROOM BURCH G10
EVANSTON IL 60201
PRIORITY LAB REPORT
DEPARTMENT OF PATHOLOGY AND LABORATORY MEDICINE
=======================================================================
=======================================================================
BASIC METABOLIC GROUP
GLUCOSE 138.0SODIUM 135.0POTASSIUM 4.0CHLORIDE 110.0BICARB 19.1BUN 20.0CREAT 1.0MG 2.0
FOR RESULTS AND INFORMATION CALL 847-570-4223
CSTAR
2650 RIDGE AVE ROOM BURCH G10
EVANSTON IL 60201
PRIORITY LAB REPORT
DEPARTMENT OF PATHOLOGY AND LABORATORY MEDICINE
=======================================================================
=======================================================================
LIVER FUNCTION PANELresult
ALBUMIN 4.1 4.0T.BIL 1.0 0.7D.BIL 0.1 0.2SGOT 20.0 21SGPT 30.0 24
FOR RESULTS AND INFORMATION CALL 847-570-2113
CSTAR
2650 RIDGE AVE ROOM G901D
EVANSTON IL 60201
PRIORITY LAB REPORT
DEPARTMENT OF PATHOLOGY AND LABORATORY MEDICINE
=======================================================================
=======================================================================
LIPASELIPASE 15
AMYLASEAMYLASE 20
FOR RESULTS AND INFORMATION CALL 847-570-4223
CSTAR
2650 RIDGE AVE ROOM BURCH G10
EVANSTON IL 60201
PRIORITY LAB REPORT
==================================================================================
==================================================================================
CARDIAC PANEL
TROPONIN I 0.03
MYOGLOBIN 90
CKMB 2.5
FOR RESULTS AND INFORMATION CALL 847-570-2113
CSTAR
2650 RIDGE AVE ROOM G901D
EVANSTON IL 60201
PRIORITY LAB REPORT
DEPARTMENT OF PATHOLOGY AND
LABORATORY MEDICINE
==================================================================================
==================================================================================
COAGULATION PANEL
PT 10.0
INR 1.0
PTT 30.0
FOR RESULTS AND INFORMATION CALL 847-570-2113
CSTAR
2650 RIDGE AVE ROOM G901D
EVANSTON IL 60201
PRIORITY LAB REPORT
DEPARTMENT OF PATHOLOGY AND
LABORATORY MEDICINE
==================================================================================
==================================================================================
TOX SCREENURINE
AMPHETAMINE NEGBARBITURATE NEGOPIATE NEGPHENCYCLIDINE NEGMETHADONE NEGBENZODIAZEPINE NEG
SERUMALCOHOL 0SALICYLATES <40ACETAMINOPHEN <10
FOR RESULTS AND INFORMATION CALL 847-570-2113
CSTAR
2650 RIDGE AVE ROOM G901D
EVANSTON IL 60201
PRIORITY LAB REPORT
DEPARTMENT OF PATHOLOGY AND LABORATORY MEDICINE
=======================================================================
=======================================================================
TSH <0.002
FOR RESULTS AND INFORMATION CALL 847-570-4223
CSTAR
2650 RIDGE AVE ROOM BURCH G10
EVANSTON IL 60201
PRIORITY LAB REPORT
References:Stephanie L. Lee, MD, Phd, FACEP (emedicine.com, Hyperthyroidism)www.emedicine.com/med/topic1109.htmMarch 3, 2004
Sarlis, NJ and L Gourgiotis (2003). Thyroid Emergencies. Reviews in Endocrine and Metabolic Disorders 4: 129-136.
[5]
1. Dronen, S.S., Scott;Keim, Sam; Chisholm, Carey; Ling,Louis Model Curriculum for Emergency Medicine Residency Training 2000, SAEM
2. Hockberger, R.S., 2003 Model of the Clinical Practice of Emergency Medicine C.o.R. Directors, Editor. 2003.
3. Hockberger, R.S., et al., The Model of the Clinical Practice of Emergency Medicine: A Two-Year Update. Acad Emerg Med, 2005. 12(6): p. 543-558.
4. McKeown, N.J., et al., Hyperthyroidism. Emerg Med Clin North Am, 2005. 23(3): p. 669-85, viii.
5. Wald, D.A. and A. Silver, Cardiovascular manifestations of thyroid storm: a case report. J Emerg Med, 2003. 25(1): p. 23-8.