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Identifying and Treating Thyroid Storm and Myxedema Coma in the Emergency Department Mills L

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Identifying and Treating Thyroid Storm and Myxedema Coma in the Emergency Department Mills L Years Improving Patient Care August 2009 Identifying And Treating Volume 11, Number 8 Thyroid Storm And Myxedema Authors Lisa Mills, MD Director, Emergency Medicine Ultrasound, Associate Professor, Coma In The Emergency Emergency Medicine, Louisiana State University at New Orleans, New Orleans, LA Stephen Lim, MBBS Department Staff Physician, Department of Emergency Medicine, Leonard J. Chabert Medical Center, Houma, LA Case #1: A 65-year-old woman is brought to the emergency department Peer Reviewers (ED) with altered level of consciousness and hypotension. Her neighbor Michael S. Radeos, MD, MPH found her on the kitchen floor. He checked on her because he hadn’t seen her Assistant Professor of Emergency Medicine, Weill Medical for 3 days. The patient is unable to provide any verbal history. Her vital College of Cornell University, New York, NY signs are respiratory rate of 10 respirations per min, blood pressure of 90/60 Corey M. Slovis, MD, FACP, FACEP mm Hg, temperature 35°C (95°F), and heart rate 50 beats per min. On Professor and Chair, Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN physical examination, you see an obtunded woman in no apparent distress. CME Objectives You note a well-healed surgical scar on her anterior neck and that her left Upon completion of this article, you should be able to: leg is shortened and externally rotated. The differential diagnosis of the 1. Identify presenting signs and symptoms of a thyroid crisis. presentation is long and complex, and you keep wondering if that scar on 2. Discuss the treatment of myxedema coma. the neck has a bearing on her management. 3. Discuss the treatment of thyroid storm. 4. Name the groups at risk for myxedema coma. Case #2: A 50-year-old man presents with complaints of a fever and 5. Name inciting events for thyroid crises “feeling anxious.” The patient has had a productive cough, subjective Date of original release: August 1, 2009 fever, and myalgias for 7 days. Yesterday, he began to “feel anxious” and Date of most recent review: May 26, 2009 Termination date: August 1, 2012 like his “heart was racing.” His past medical history is significant for a Medium: Print and online goiter that is still being evaluated. His vital signs are respiratory rate of 18 Method of participation: Print or online answer form and evaluation respirations per min, blood pressure of 160/80 mm Hg, temperature 38°C Prior to beginning this activity, see “Physician CME (100.4°F), and heart rate 140 beats per min. On physical examination, you Information” on page 22. note that the patient appears nontoxic. He has a tender goiter, a fine tremor of his hands, and an irregular heart rhythm. On his lung examination, there are left midfield rales. You suspect community-acquired pneumonia, but the tender goiter introduces management concerns. Editor-in-Chief Francis M. Fesmire, MD, FACEP University, Washington, DC;Director Thomas Jefferson University, Research Editors Andy Jagoda, MD, FACEP Director, Heart-Stroke Center, of Academic Affairs, Best Practices, Philadelphia, PA Erlanger Medical Center; Assistant Inc, Inova Fairfax Hospital, Falls Lisa Jacobson, MD Professor and Chair, Department Scott Silvers, MD, FACEP Professor, UT College of Medicine, Chief Resident, Mount Sinai School of Emergency Medicine, Mount Church, VA Medical Director, Department of Chattanooga, TN of Medicine, Emergency Medicine Sinai School of Medicine; Medical Keith A. Marill, MD Emergency Medicine, Mayo Clinic, Residency, New York, NY Director, Mount Sinai Hospital, New Assistant Professor, Department of Jacksonville, FL Nicholas Genes, MD, PhD International Editors York, NY Instructor, Department of Emergency Medicine, Massachusetts Corey M. Slovis, MD, FACP, FACEP Editorial Board Emergency Medicine, Mount Sinai General Hospital, Harvard Medical Peter Cameron, MD School, Boston, MA Professor and Chair, Department William J. Brady, MD School of Medicine, New York, NY of Emergency Medicine, Vanderbilt Chair, Emergency Medicine, Professor of Emergency Medicine Michael A. Gibbs, MD, FACEP Charles V. Pollack, Jr., MA, MD, University Medical Center, Monash University; Alfred Hospital, and Medicine Vice Chair of Chief, Department of Emergency FACEP Nashville, TN Melbourne, Australia Emergency Medicine, University Medicine, Maine Medical Center, Chairman, Department of Amin Antoine Kazzi, MD, FAAEM of Virginia School of Medicine, Emergency Medicine, Pennsylvania Jenny Walker, MD, MPH, MSW Portland, ME Assistant Professor; Division Chief, Associate Professor and Vice Charlottesville, VA Hospital, University of Pennsylvania Chair, Department of Emergency Steven A. Godwin, MD, FACEP Health System, Philadelphia, PA Family Medicine, Department Peter DeBlieux, MD Associate Professor, Associate of Community and Preventive Medicine, University of California, Professor of Clinical Medicine, Chair and Chief of Service, Michael S. Radeos, MD, MPH Medicine, Mount Sinai Medical Irvine; American University, Beirut, LSU Health Science Center; Department of Emergency Medicine, Assistant Professor of Emergency Center, New York, NY Lebanon Director of Emergency Medicine Assistant Dean, Simulation Medicine, Weill Medical College of Hugo Peralta, MD Services, University Hospital, New Cornell University, New York, NY. Ron M. Walls, MD Education, University of Florida Professor and Chair, Department Chair of Emergency Services, Orleans, LA COM-Jacksonville, Jacksonville, FL Robert L. Rogers, MD, FACEP, of Emergency Medicine, Brigham Hospital Italiano, Buenos Aires, Wyatt W. Decker, MD Gregory L. Henry, MD, FACEP FAAEM, FACP and Women’s Hospital,Harvard Argentina Associate Professor of Emergency CEO, Medical Practice Risk Assistant Professor of Emergency Medical School, Boston, MA Maarten Simons, MD, PhD Medicine, Mayo Clinic College of Medicine, The University of Assessment, Inc.; Clinical Professor Scott Weingart, MD Emergency Medicine Residency Medicine, Rochester, MN Maryland School of Medicine, of Emergency Medicine, University Assistant Professor of Emergency Director, OLVG Hospital, Baltimore, MD of Michigan, Ann Arbor, MI Medicine, Elmhurst Hospital Amsterdam, The Netherlands John M. Howell, MD, FACEP Alfred Sacchetti, MD, FACEP Center, Mount Sinai School of Clinical Professor of Emergency Assistant Clinical Professor, Medicine, New York, NY Medicine, George Washington Department of Emergency Medicine, Accreditation: This activity has been planned and implemented in accordance with the Essentials and Standards of the Accreditation Council for Continuing Medical Education (ACCME) through the sponsorship of EB Medicine. EB Medicine is accredited by the ACCME to provide continuing medical education for physicians. Faculty Disclosure: Dr. Mills, Dr. Lim, Dr. Slovis, Dr. Radeos, and their related parties report no significant financial interest or other relationship with the manufacturer(s) of any commercial product(s) discussed in this educational presentation. Commercial Support: This issue of Emergency Medicine Practice did not receive any commercial support. lthough thyroid-related medical conditions are III reported the incidence of subclinical and clinical Arelatively common in the general population, hyperthyroidism to be approximately 1%, with a the acute life-threatening thyroid emergency rarely roughly equal distribution between the two. Hypo- presents. Both hyper- and hypothyroidism can thyroidism is more prevalent, with a reported inci- contribute to the etiology of a number of critical ED dence of approximately 1% to 2% overall.4 Although presentations, ranging from acute psychosis to frank overt hypothyroidism may be present in less than coma. With reported mortality rates ranging from 0.5% of the population, the incidence of subclinical 20% to 80% for the life-threatening, decompensated hypothyroidism is more prevalent and may affect up forms of hypo- and hyperthyroidism, myxedema to 10% of elderly women.4-6 Both hyper- and hypo- and thyroid storm, respectively, it remains crucial thyroidism are more common in women. that the emergency clinician be versed in their diag- The incidence of thyroid storm and myxedema nosis and treatment.1,2 coma is unknown. However, mortality rates for This issue of Emergency Medicine Practice reviews both are exceedingly high. Untreated thyroid storm the fundamental principles of the management of is fatal, and even with treatment, mortality ranges thyroid emergencies using a focused, evidenced- from 20% to 50%.7 Myxedema coma mortality rates based approach to the literature. Although thyroid as high as 80% have historically been reported, but disorders constitute a wide-ranging clinical spec- even with current treatments, mortality rates remain trum, this review will focus on the common final at 30% to 60%.8,9 Eighty percent of myxedema coma pathway of acutely decompensated hyper- and patients are women, and most of these women are hypothyroidism, myxedema, and thyroid storm. Ac- older than 60 years.10 curate diagnosis and the application of proven emer- gent treatments are critical in reducing the profound Definitions And Etiology mortality rates related to both conditions. Hyperthyroidism and hypothyroidism represent a clinical spectrum of disease. The terms hyperthy- Critical Appraisal Of The Literature roidism and hypothyroidism in the strictest sense refer to hyperfunction and hypofunction of the We performed a literature review through Ovid thyroid gland, respectively. These conditions exist MEDLINE and PubMed using the terms hyperthy- in a full
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