Essentials for emergency: "Emergency Thyroid Diagnosis and Treatment" is a comprehensive guide​

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Introduction: Hypothyroidism and hyperthyroidism are common clinical thyroid diseases, which seem to be chronic diseases in the impression of ordinary people.
In fact, thyroid diseases also have critical situations, namely thyroid emergencies, including hypothyroidism caused by severe thyroid hormone deficiency Crisis (mucinous edema coma) and hyperthyroidism caused by excess thyroid hormone (thyroid crisis).

Although these two kinds of crises are rare in clinical practice, they are hidden and progress rapidly, improperly handled, and often life-threatening.
Doctors who have no relevant handling experience are often caught off guard when they are clinically encountered.
I don’t know where to start.
, To make a summary of its diagnosis and treatment, and hope that all colleagues will be proficient in it and be prepared for unexpected needs at the critical moment.

1.
Hypothyroidism Crisis Hypothyroidism is a mucinous edema coma.
It is a clinical syndrome caused by severe hypothyroidism, systemic metabolism and decline in the function of various systems.
It is a serious complication of hypothyroidism and is often life-threatening.

It is most common in elderly women who have not been diagnosed or treated for a long time.
The prevalence of women is about 4-8 times that of men.

Infection and non-compliance with thyroid supplement treatment are the main contributing factors.

Cold-induced hypothermia or lung infections are common triggers.
Other triggers include cardiovascular events, gastrointestinal bleeding, the use of anesthetics and sedatives, amiodarone, trauma, surgery, and electrolyte acid-base balance disorders.

1.
Clinical features (1) Changes in the nervous system The nervous system can produce various complications, such as mental retardation, forgetfulness, mood swings, depression and persecution delusions, etc.
In severe cases, lethargy, lethargy or even coma may occur, and some patients may have epileptic seizures .

 (2) Changes in vital signs Hypothermia-the lower the body temperature, the worse the prognosis.

In addition, patients may also have clinical manifestations such as decreased blood pressure, decreased heart rate, and slow breathing.

If the cause of the disease is infection, the patient may not have fever symptoms, and you need to be vigilant at this time.

 (3) Patients may have dry skin, thinning hair, hoarse voice, delayed or disappeared tendon reflexes, megaglossia, non-pitting edema, goiter, etc.
, shock, multiple organ failure, and even death.

 2.
Diagnosis In the emergency department, all elderly and unconscious patients should pay attention to inquiring about the history of hypothyroidism and detailed physical examination to increase the test rate of thyroid function to rule out the disease.

The typical physical examination of this disease shows edema, dullness, thick lips, wide nose, large tongue, cold skin, sallow, rough, poor elasticity, thinning, dry, lack of luster, few eyebrows, and often shedding of the outer third .

Skin edema is mainly non-pitting.

The thyroid gland is not obvious in most patients.

Patients with hypothermia and neurological abnormalities, and clinical and biochemical features suggest that hypothyroidism should be highly suspected of this disease.

 3.
Treatment measures (1) Removal of inducements: The incidence of infection is more common.
Antibiotics can be used preventively until the infection factor is eliminated, and the application of diuretics, sedatives and other drugs should be avoided.

 (2) Thyroid hormone supplementation: Levothyroxine sodium (L-T4) is 200-400ug for the first time, and 1.
6ug/kg is injected daily, and the patient is awake and changed to oral.

If there is no injection, nasal feeding with tablets can be given.

If there is no significant improvement in the condition within 24 hours, you can consider changing to T3 intravenous injection, 10ug q4h or 25ug q8h; the dose should be reduced in elderly patients and accompanied by cardiac complications, and the dose during pregnancy should be increased.

 (3) Adrenal cortex hormone supplementation: In severe hypothyroidism, the function of the pituitary-adrenal axis will also be impaired.
Exogenous thyroid hormone supplementation may also induce adrenal crisis.
Therefore, adrenal cortex hormone supplementation: intravenous hydrogenation can be used.
200-400mg qd of pine, gradually reduce the dose after the patient is awake.

 (4) Insulation: Keep the core temperature, avoid increasing the body surface temperature, and do not use electric blankets, etc.
(may cause peripheral blood vessel dilation and aggravate blood volume deficiency).  (5) Correct water and electrolyte disorders: proper fluid replacement and blood transfusion if necessary.

Attention should be paid to monitoring the intake and output, cardiac function, and electrolytes during fluid rehydration.

 (6) Other supportive therapies: oxygen inhalation, keeping the airway unobstructed, tracheotomy and mechanical ventilation if necessary.

Use vasoactive drugs to maintain blood pressure and correct hypoglycemia.

 2.
Hyperthyroidism crisis Hyperthyroidism crisis is a kind of emergency in which the condition of hyper nails suddenly aggravates and is life-threatening under the action of certain inducements.
It is medically called thyroid crisis, or thyroid storm.

It is more common in patients with long-term and untreated hyperthyroidism (Graves disease, multiple nodular goiter, solitary toxic adenoma).

Rare thyroid crisis can be secondary to subacute thyroiditis or thyrotoxicosis caused by excessive intake of thyroid hormone.

It is usually caused by acute events such as thyroid or non-thyroid surgery, trauma, infection, extreme weather, metabolic disorders, drugs, acute iodine load drugs (iodine 131 treatment, use of amiodarone or iodine-containing contrast agents, etc.
), childbirth, etc.

If the disease is not treated well, the patient will often die from heart failure and shock, with a mortality rate of up to 20%.

Early diagnosis and reasonable treatment are particularly important.

 1.
Clinical features (1) Dysfunction of body temperature regulation: high fever, usually 39°C, accompanied by profuse sweating, skin flushing, skin paleness and dehydration may appear later.

(2) Central nervous system: anxiety, irritability, gradual development of delirium, lethargy, and finally coma.

(3) Circulatory system: the heart rate is often> 160 beats/min, which is not proportional to the increase in body temperature.
Arrhythmia (especially atrial fibrillation and supraventricular tachycardia) may occur, and pulmonary edema and congestive heart failure may occur easily.
, There was shock.

(4) Digestive system: nausea, vomiting, diarrhea, diffuse abdominal pain, liver enlargement.
Few patients will experience liver insufficiency, jaundice, and liver failure.
If jaundice occurs, it indicates a poor prognosis. (5) Water and electrolyte disorders: Due to poor appetite, vomiting, diarrhea, and excessive sweating, water and electrolyte disorders are often combined with insufficient blood volume, which further leads to the occurrence of orthostatic hypotension and shock.

 2.
Diagnosis There is no recognized standard or effective clinical tool for diagnosing thyroid crisis.

 When the patient has high fever (≥38℃), obvious tachycardia (≥130/min), atrial fibrillation, congestive heart failure, disturbance of consciousness and gastrointestinal symptoms (such as nausea, vomiting, diarrhea and jaundice), especially when When symptoms originating from multiple organ systems are observed at the same time, the possibility of thyroid crisis should be suspected.

If the patient has a history of treatment for Graves disease, a family history of thyroid disease and a history of short-term weight loss, as well as goiter, anterior cervical murmur and exophthalmos, the possibility of thyroid crisis is much higher.

You can also refer to Burch and Wartofsky's assessment of hyperthyroidism crisis in 1993 in the form of scoring.
This scoring standard includes the presence or absence of triggers, body temperature, heart rate, presence or absence of heart failure and atrial fibrillation, central nervous system and digestive system performance, <25 points Excluding hyperthyroidism, 25-44 is divided into pre-hyperthyroid crisis, ≥45 points can be considered for hyperthyroid crisis, the specific score details are shown in the table below.

  Table 1 Burch and Wartofsky semi-quantitative clinical criteria for thyroid crisis Note: A score of less than 25 points to exclude hyperthyroidism, a score of 25-44 is divided into pre-hyperthyroidism crisis, and a point of more than 45 points can be considered for hyperthyroidism.
3.
Treatment measures (1) Antithyroid drugs Application: Propylthiouracil (PTU) is the first choice, 600 mg orally for the first time, gastric tube infusion or rectal administration for comatose or uncooperative patients, followed by 200 mg q8h, and gradually reduce the dose to the regular dose after symptoms improve.

(2) Iodine: 1 to 2 hours after taking antithyroid drugs (such as propylthiouracil), the first dose is 30 to 60 drops, and then 5 to 10 drops every 6 to 8 hours.

After that, the dosage is gradually reduced according to the condition, and the drug is generally stopped after 3 to 7 days to prevent the occurrence of "iodine escape phenomenon".

Or 1g sodium iodide dissolved in 500ml liquid, intravenous drip, 1-3g/d; generally, the drug can be stopped after 3-7 days.

(3) Glucocorticoids: Hydrocortisone starting at 300 mg, followed by intravenous injection of 100 mg every 8 hours is a routine treatment option for thyroid crisis.

After the condition improves, the dose is gradually reduced or even stopped, and the time of intravenous use of hormones generally does not exceed 1 week.

(4) Bile acid sequestrants can help reduce thyroid hormone levels in patients with thyrotoxicosis by interfering with intestinal hepatic circulation and thyroid hormone recycling (such as cholestyramine 4g, orally 4 times, 4 times a day).

(5) Beta receptor blocker: Propranolol inhibits the conversion of T₄ to T₃ in peripheral tissues.
It can be used for patients without heart failure to relieve symptoms.
Oral propranolol 10-40mg once every 4-6h, or 2mg Intravenous injection; if there are contraindications to the use of β-blockers, calcium channel blocker diltiazem can be used to slow the heart rate, 60mg-90mg orally every 6-8 hours; but for people with cardiac insufficiency, heart block, atrial flutter, and bronchial Patients with asthma should be cautious or ban β-blockers.
If necessary, short-acting preparations such as esmolol should be used at a dose of 250-500ug/kg, followed by infusion of 50-100ug/kg/min.
Note.

(6) Treatment for the sudden cause of the disease: In all cases of thyroid crisis, the cause of the disease should be found and the underlying disease should be treated immediately.

(7) Other adjuvant treatments: ① Patients with extremely severe hemodialysis/plasma exchange may have antithyroid drugs and the above treatments are not enough to quickly reduce blood thyroxine levels, or those who cannot use antithyroid drugs due to antithyroid drug allergies, are using the above Adding hemodialysis or plasma exchange on the basis of treatment can significantly reduce the level of thyroid hormone within 36 hours.

 ②Infusion of plasma and albumin: It can increase the binding capacity of thyroid hormone and reduce the level of free thyroid hormone.

 ③ Those with heart failure and pulmonary congestion can use digitalis and diuretics, and those with atrial fibrillation with rapid heart rate can use digitalis and calcium channel antagonists.

 ④ Supportive treatment: Oxygen, supplement of energy and a lot of vitamins (especially B group), and correct water and electrolyte disorders.

 Antipyretics such as paracetamol can be used to reduce fever and temperature.
Patients with high fever must use physical cooling measures such as ice packs and alcohol baths.
If necessary, implement artificial hibernation therapy (pethidine 100mg, chlorpromazine and promethazine each 50mg mixed intravenously Continuous pumping) (Avoid the use of salicylic acid preparations, because they can competitively bind to thyroid hormone binding globulin and increase the levels of free T3 and free T4.
Large doses of salicylic acid preparations can also speed up the metabolic rate).

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