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Acute Thyrotoxic Crisis, Tachycardia and Arrhythmias VICTOR PARSONS DAVID JEWITT* D.M., M.R.C.P

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Acute Thyrotoxic Crisis, Tachycardia and Arrhythmias VICTOR PARSONS DAVID JEWITT* D.M., M.R.C.P Postgrad Med J: first published as 10.1136/pgmj.43.506.756 on 1 December 1967. Downloaded from Postgrad. med. J. (December 1967) 43, 756-762. Beta-adrenergic blockade in the management of acute thyrotoxic crisis, tachycardia and arrhythmias VICTOR PARSONS DAVID JEWITT* D.M., M.R.C.P. B.Sc., M.R.C.P. Senior Lecturer Lecturer in Medicine Department of Medicine, King's College Hospital, London, S.E.S TACHYCARDIA is a characteristic feature of thyro- arrhythmia and tremor (Rowlands, Howitt & toxicosis at all ages, but the older the patient the Markham, 1965; Howitt & Rowlands, 1966). more frequent the occurrence of atrial fibrillation. The pharmacology of sympathetic-blocking Treatment of thyrotoxicosis is followed by slow- drugs in thyrotoxicosis has been recently reviewed ing of heart rate and more than half of the (Harrison, 1964). thyrotoxic patients with atrial fibrillation, who Encouraged by these reports we first used are treated with anti-thyroid drugs or surgery pronethalol and later propranolol to treat the (Sandler & Wilson, 1959) or radioactive iodine occasional thyrotoxic patient who required urgent therapy (Staffurth, Gibberd & Hilton, 1965) revert control of tachycardia, cardiac arrhythmia and to sinus rhythm. Until thyrotoxicosis is controlled the hypermetabolic state. the tachycardia is resistant to digitalis therapy unless a larger dose is employed (McMichael, Clinical groups studied 1963) and this feature may itself indicate the (I) Patients in a thyrotoxic crisis or 'storm'. diagnosis of occult thyrotoxicosis (Cookson, 1959). with (2) Patients thyrotoxicosis who presented copyright. Even shifts in the protein-binding of thyroxine with disabling tachycardia, arrhythmia, or may play a part in supraventricular tachycardias palpitations pending response to anti- (Schatz, 1967). The circulatory features of thyro- thyroid drugs. toxicosis are usually a marked feature of the (3) Patientswhose thyrotoxicosis was associated thyrotoxic crisis or storm, when tachycardia is with an independent cardiac lesion. associated with hyperpyrexia, diarrhoea, psychiatric (4) Thyrotoxic patients requiring urgent surgi- disturbance, muscle weakness and profuse sweat- cal operation before control could be ing (Ingbar, 1966). achieved by routine anti-thyroid measures. Urgent control of the tachycardia, cardiac and state are arrhythmias the hypermetabolic Thyrotoxic crisis http://pmj.bmj.com/ occasionally required, notably when a fully es- tablished crisis develops. In this situation blockade (1) S.B., a 40-year-old motor mechanic, who of the sympathetic nervous system or depletion had a goitre at the age of 12, developed acute of catecholamines of thyrotoxicosis at the age of 38, with loss of weight, of tissue stores may be severe tremor and dyspnoea on exertion. He was value. The first reports of a striking improvement given Lugol's iodine in preparation for thyroid- in patients with thyrotoxic crisis were those treat- ectomy but improvement was so encouraging that ed by epidural block (Crile, 1929) and later he using spinal anaesthesia (Knight, 1945). It was declined surgery, and defaulted from super- on October 1, 2021 by guest. Protected suggested that the circulatory changes were due vision for 2 years, taking iodine regularly. When to to catechol- seen again he had a very large nodular goitre and increased peripheral responsiveness was mildly thyrotoxic with a regular pulse rate amines (Brewster et al., 1956), no evidence being of 100/min. Further preparation was attempted found for an absolute increase in their output but (Wisewell et al., 1963). Reserpine was found to control was difficult; finally sub-total thyroid- be effective in controlling thyrotoxic symptoms ectomy was carried out, followed 3 days later by (Canary et al., 1959) and sympathetic blockade a thyrotoxic crisis, hyperpyrexia, disorientation, by guanethidine has been used increasingly dyspnoea and atrial flutter of 330/min with 2: 1 (Degroot et al., 1961; Leak, 1963; Waldstein block. In the next 4 days he received 7 mg of et similar success. digoxin and 1,5 g of quinidine with no obvious al., 1964) with Recently pro- improvement; atrial flutter remained at 320/min pranolol has been tried in thyrotoxic tachycardia, with the block alternating between 2:1 and 4: 1. *Present appointment: Senior Registrar, Department of After 600 mg of pronethanol in 24 hr the pulse Medicine, Hammersmith Hospital. rate had fallen to 80/min and an ECG showed Postgrad Med J: first published as 10.1136/pgmj.43.506.756 on 1 December 1967. Downloaded from Beta-adrenergic blockade 757 sinus rhythm. He was maintained on 600 mg of anti-thyroid medication because of a slight rash pronethanol daily for a further 2 weeks and over his thighs. He did not return for 2 weeks, although the immediate decrease in pulse rate, being away on business. He was then admitted in hyperpyrexia and general excitement were the thyroid crisis with an acute psychosis characterized only objective signs of improvement, they were by derealization, hallucinations and ideas of immediate and thought not to be due only to reference with paranoid features. He ran a fever thyroidectomy. of 38-5°C and a tachycardia of 110/min, regular (2) I.W., a 35-year-old housewife, was admitted rhythm, having lost 3 kg in weight. Treatment was to an observation ward with an acute agitated started with 60 mg of propranolol and 300 mg of depression. She volunteered a long history of chlorpromazine a day. Within 48 hr all the features anxiety and distress with acute symptoms for 5 of the psychosis had gone, the tachycardia was weeks. Three years previously she had refused reduced to 90/min and his pyrexia had subsided. thyroidectomy at another hospital and had taken An anti-thyroid drug, methylthiouracil, 600 mg/ medication sporadically; owing to her psychiatric day, was introduced 2 days later without a state, both her children had been taken into care. recurrence of the rash and his thyrotoxicosis came On examination she was extremely agitated and under control slowly within 2 weeks, propranolol emotionally labile; her hands were tremulous and and chlorpromazine being discontinued at this sweating; there were no eye signs. She had a large time. smooth goitre with a retrosternal projection. Pulse (4) C.B., a single 35-year-old brewery worker, varied between 160 and 120/min, sinus rhythm. was troubled by a swelling in his neck for 5 Blood pressure 128/85 with no signs of heart years, with dyspnoea at night for some weeks. In failure. Investigations: protein bound iodine his past he had had meningitis as a child, which 11-6 ttg/100 ml. ECG: sinus tachycardia- had left him mentally defective. There was no 140/min. Before transfer to a general hospital she family history of thyroid disease. On examination had been under sedation with chlorpromazine, he was of muscular physique with no signs of 75 mg/day; this was discontinued for 2 days thyrotoxicosis; no deafness could be detected on without much change in her condition. Propranolol simple questioning. A large goitre in the neck copyright. was given, 120 mg/day for 48 hr and then 60 mg caused stridor on acute flexion or extension of for 72 hr. There was an immediate fall in pulse the neck, there being a retrosternal projection. rate to 90/min although tremor continued. Her Pulse 85/min (sleeping), blood pressure 130/80. agitation improved considerably at the same time Indirect laryngoscopy revealed a polypoid kera- as her tachycardia decreased. An anti-thyroid tinized mass on one vocal cord accounting for drug, carbimazole, 60 mg/day, was commenced at part of his stridor. Investigation revealed a this stage and propranolol discontinued owing to normal 13l1 uptake, which was evenly distributed gastric discomfort and the development of venous across the gland. He was admitted and received thrombosis. Her tachycardia rebounded to 140/ Lugol's iodine for 2 days to prior surgery. A http://pmj.bmj.com/ min and came slowly under control over a large colloid goitre was removed without incident. week on the re-introduction of chlorpromazine, Within 24 hr he suddenly became dyspnoeic, pulse 75-125 mg/day. A further relapse of her agitation 144/min, sinus rhythm, pryexia to 101'F with and tachycardia to 120/min responded to the gross tremor, sweating and mild anxiety. Investiga- addition of reserpine 0-5 mg/day for a further 10 tions at this time revealed a PBI of 105 ,ug/100 ml days. Thyroidectomy was carried out 8 weeks but a butanol El of only 1 ug/I00 ml, and VMA later, a gland of 280 g being removed without excretion of 9.9 mg in 24 hr. Chest X-ray: some mishap. basal congestion but no signs of heart failure. on October 1, 2021 by guest. Protected (3) J.R., a 28-year-old business representative, Serum electrolyte concentrations normal. He presented with a history of slight protuberance of received propranolol, 20 mg t.d.s. In less than one eye for 6 weeks, loss of weight and mild 4 hr the pluse rate and pyrexia had subsided and anxiety. There was no family history of thyroid he was much calmer. Electrocardiograms taken disorder, nor personal history of mental illness. at the time and later showed no evidence of On examination there was slight lid-lag but no arrhythmia. exophthalmos, a regular tachycardia of 90/min and slight goitre but no bruit. Investigation Patients with tachyeardia and arrhythmia showed a serum PBL of 15-4 ug/100 ml. He Because of the encouraging results in the treat- was treated with mild sedation and 45 mg of ment of the acute tachycardia and arrhythmia carbimazole a day in preparation for surgery if accompanying thyrotoxic crisis it was thought his exophthalmos did not become acute. While worthwhile to try the effects of sympathetic beta- an out-patient 3 weeks later he discontinued his blocking agents in a number of patients who had Postgrad Med J: first published as 10.1136/pgmj.43.506.756 on 1 December 1967.
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