By Saud Al-Sulimani

1. Case presentation Suad Al-Sulimani

2. outline Case presentation Case discussion Topic review

3. 23 years old male sudden onset of SOB & palpitation 1 day duration

4. Primary survey

5. Generally: A:patent no secretion Anxious , Irritable , sweaty Contious , orianted

6. B: Dyspnic RR:22/min spo2 100% in RA Chest : clear Generally: Anxious hyperventilating Contious , orianted A: patent no secretion

7. B: Dyspnic RR:22/min spo2 100% in RA Chest : bilaterally clear Generally Anxious hyperventilating Contious , orianted A: patent no secretion C: Pr:140/min (regular , good volume) bp164/90 mmhg

8. B: Dyspnic RR:22/min spo2 98% in RA Chest : clear Generally: Anxious hyperventilating Contious , orianted A: patent no secretion C: Pr:140/min ( regular , good volume) Bp 164/90mmhg D: Reflow:6.8 Pupils: bilaterally reactive GCS: 15/15

9. B: Dyspnic RR:22/min spo2 98% with 100% o2 Chest : clear Generally: Anxious hyperventilating Contious , orianted A: patent no secretion E: No obvious external injuries or bleeding Temp:afebrile C: Pr:140/min (regular , good volume ) bp150/60 D: Reflow:6.8 Pupils:bilaterally reactive GCS: 15/15

10. history = young male , unmarried , work as water tank driver = after stressful event at home, was driving his car , suddenly has sob , palpitation , became dizzy = stopped the car , call for help = associated chest pain :unspecific , left sidedchest , burning , withsweating

11. Since 3 mounths , have onn/off chest pain , mainly after stress , not related to excertions , associated with sweating & palpitation

12. No cough or fever No GI symptoms No h/o contact with sick person No recent travel. Never smoke or drink alcohol. Denying h/o drug intake No FH of sudden death or CAD

13. Examination: Hyperventilating Not ecteric , no skin rash , not dehydrated , no neck stiffness Fundoscopy : no papilodema JVP:not raised, no pedal edema Chest:, clear CVS: normal s1s2, no added sounds Abdomen is soft, no hepatomegaly.

14. Differential diagnosis Cardiac :Arrhythmias ,ACS ,Cardiomyopathy Pericarditis Respiratory :Pulmonary embolism Endocrine : Hyperthyrodism ( thyroid storm ) , Phyochromocytoma Drug overdose : sympethatomimatic , anticholenergic Psychological :Hyperventilation , anxiety disorders

15. ECG

16. Chest x-ray

17. Trop T < .014, repeated Trop T <.014

18. Action taking Midazolam total of 13 mg ABG : Po2 118 , PH 7.4 , Pco2 22

19. Bedside Echo ( done by cardiologist ): Normal , good EF , no evidence of pericarditis

21. Urea:3.8, creat:68, K: 4.3, Na:143

22. Salicylate level :normal

23. TSH < .003 (.35-4.9 )

24. Free T4 42 .6 (8.2 – 22.6 )

26. Admitted in HiDe , monitored for 48 hrs Remain tachycardia ,PR 128/min , high BP 180/70 , maintaining sat , c/o sweating His BP controlled with IV Labetelol Started on Propranolol Carbimazol & lugol’s iodenine solution 1 ml tid for 1 week

27. BP controlled , PR improved 100/min , 80/min 24-hour urine catecholamines and metanephrines was done , came as normal Discharged home after 4 days on Carbimazol &n Propranolol with f/u appointment in Endocrine clinic

28. Thyroid Storm

29. Thyroid Storm The overall incidence of hyperthyroidism is estimated between 0.05% and 1.3% Thyroid storm is a rare disorder. Approximately 1-2% of patients with hyperthyroidism progress to thyroid storm Mortality approximately 10-20%, but it has been reported to be as high as 75% in hospitalized populations. Underlying precipitating illness may contribute to high mortality.

31. Thyroid Storm Causes Untreated hyperthyrodism Infections, especially of the lung Thyroid surgery in patients with overactive thyroid gland Stopping medications given for hyperthyroidism Too high of thyroid dose Treatment with radioactive iodine Pregnancy Heart attack or heart emergencies Emotional stress

32. Thyroid Storm Symptoms Rapid heart beats Greatly increased body temperatur Chest pain Shortness of breath Anxiety and irritability Disorientation Increased sweating Weakness Heart failure

33. Fever ranges from 100.4-105.5. The pulse rate may range between 120 and 200 beats per minute but has been reported as high as 300 . . . sweating so profuse as to lead to dehydration from insensible fluid loss . . .

34. Medical Treatment A complete evaluation to determine the cause of thyroid storm Intravenous fluids and electrolytes Oxygen if needed Fever control with antipyretics (fever-reducing medications) and if needed cooling blankets Intravenous corticosteroids such as hydrocortisone

35. Defenitivetratment Medications to block the production of thyroid hormones, such as propylthiouracil (PTU) or methimazole Iodide to block thyroid hormone release Block the action of thyroid hormones on the cells by drugs called beta-blockers, such as propranolol (Inderal) Treatment of heart failure if present

36. Next Steps Following the start of treatment, careful monitoring, usually in the intensive care unit, is necessary. Following recovery from thyroid storm, options for definitive treatment are radioactiveiodine or antithyroid medications; surgery is rarely needed.

37. Rescue PCI Rescue PCI is reasonable for selected patients 75 years or older with ST elevation or LBBB or who develop shock within 36 hours of MI It is reasonable to perform rescue PCI for patients with one or more of the following: a. Hemodynamic or electrical instability b. Persistent ischemic symptoms.