Beruflich Dokumente
Kultur Dokumente
2005 (30)
Askandar Tjokroprawiro
Diabetes and Nutrition Center Airlangga University School of Medicine - Dr. Soetomo Teaching Hospital, Surabaya
1 General Symptoms : - Fever (>38.5 0C, Frequently >40 0C) Tachycardia >120/min
- Profuse Sweating, Respiratory Distress, Fatigue
1 Never Forget (!) that the Dx for TS is Clinically Based 2 No Laboratory Tests are Diagnostic 3 Special Attention :
Should Positive Clinical Pattern of TS has been Confirmed, Never Delay Treatment to Await Laboratory Results
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1 Results of Thyroid Studies : Consistent with Hypertyroidism These are Useful if Pts has not been Diagnosed Previously 2 Test Results may not come back quickly Usually, such Results are unhelpful for Immediate Management 3 Usual Findings : Increased FT3 and FT4, Decreased TSHS TSH is not Suppressed if the Etiology is Excess TSH Secretion
4 LFT : Non Specific Abnormalities : ALT, AST, LDH, CK, Alkaline Phosphatase, Serum Bilirubin
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5 Pregnancy 6 Anticholinergic and Adrenergic Drugs f.e. Pseudoephedrine 7 TH Ingestion 8 Diabetic Ketoacidosis
Mortality : - In the Past 90% - Today < 20% (Better Control, Early Treatment)
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5 Withdrawal of Antithyroid Drug Therapy 17 Congestive Heart Failure 6 Radioiodine Therapy 18 Toxemia of Pregnancy 7 Diabetic Ketoacidosis 8 9 Parturition Severe Emotional Stress 19 Bowel Infarction 20 Tooth Extraction 21 TH Ingestion 22 Burn Injury 23 Sepsis 24 Childbirth
Normal : 1 TSH
T = Trimester
III Increased : 1 Thyroid Size by 10-20% (hCG Stimulation and Relative Iodide Deficiency) 2 TG (Coresponds to Increase in Thyroid Size) 3 TBG : - Reduced Hepatic Clearance - Synthesis due to Stimulation by Estrogen Concentration : Plateaus at 20 weeks of Gestation; Falls again Post Partally 4 Total T4 and T3 ( rise in TBG) 5 Small Rise in FT4 and FT3 in T-1 (hCG Stim, and then into Normal Range)
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10
1 It contains 39% Iodine by Weight 2 On a Dose of 200-600 mg/daily 7.21 mg Iodine is made available The Optimal Daily Iodine Intake : 150-200 g 3 Half-Life of Amiodarone : 52.6 Days, SD : 23.7 Days 4 Abnormalities of Thyroid Function : Up to 50% USA and UK : - 2% AIT (Amiodarone - induced Thyrotoxicosis) - 13% AIH (Amiodarone - induced Hypothyroidism) 5 AIT may present several months after discontinuing the drug
Continued
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11
6 Thyroid Function Tests : Should be monitored every 6 months 7 The High Iodine Content of Amiodarone may : a Inhibit Synthesis and Release of TH AIH b or Loading to Iodine-induced Thyrotoxicosis 8 Direct Toxic Effect of Amiodarone AIT Type-II
AIT Type-I
Amiodarone-induced Destructive Tyroiditis Leakage of TH from Damaged Follicles into the Circulation Can be Followed by a Transient Hypothyroid State before Euthyroidism is Restored
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12
Yes
Frequent Positive Normal Normal No
No
Infrequent Negative Decreased Very Elevated Possible
Vascularity (Doppler)
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Increased / Normal
Reduced
13
3 Central Nervous System Effects : 0-30 Absent : Mild : Agitation Moderate : Delirium Psychosis Extreme Lethargy Severe : Seizure Coma
0 10 20
30
4 Gastrointestinal-Hepatic Dysfunction : 0-20 Absent : 0 Moderate : Diarrhea 10 Nausea/Vomiting Abdominal Pain Severe : Unexplained Jaundice 20 5 Precipitant History : 0-10 Negative : Positive : Below 25 is Unlikely TS 25-44 is Impending TS 45-Greater is Highly Suggestive TS 0 10
14
25 - 44 Impending TS
2 Cardiovascular 3 CNS (5 - 25) (0 - 30) Tachycardia :5-25 Absent CHF AF :0-15 Mild
Moderate :20
:0-10 Severe
:30 Severe
15
Cardiovascular Dysfunction
Tachycardia/min CHF AF
Temperature 0C
38.4 - 38.8 : 15
38.9 - 39.4 : 20 39.5 - 39.9 : 25 > 40
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Severe : 15
: 30
(Pulmonary Edema)
16
2 Cardiovascular Dysfunction (5-25) a Tachycardia (90 more than 140/min) : 5 - 25 b Congestive Heart Failure : 0 - 15 c Atrial Fibrillation : 0 - 10
3 Central Nervous System Effects (0 30) 4 Gastrointestinal-Hepatic Dysfunction (0 20) 5 Precipitant History (0 10)
Diagnostic Score
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17
Goiter-Temperatur-Tachycardia-Precipitant
Go - T - TP
TTS-Score
(Clinical Experiences : 2002-2005) 1 Two of the Following : a Goiter, b Orbital Signs, c And/Or : TSHs, FT3, FT4 2 Temperature > 39.5 0C : Score > 25 3 Tachycardia > 120/min : Score > 15
18
Go - T - TP
19
FORMULA TS 41668 - 24 - 6
Practical Guidelines for the Treatment of Thyroid Storm
(Clinical Experiences : Tjokroprawiro 2002-2005)
20
Description
4-1-6-6-824-6 : Each shows Time of Treatment Period
4 1 6 6 8 24 6 Every 4 Hours of PTU-administration 1 Hour Interval between PTU (first) and Lugol (later) Administrations Every 6 Hours of Lugol-Administration Every 6 Hours of Propranolol-Administration Every 8 Hours of Hydrocortisone/Dexamethasone Treatment Clinical Improvement should occur within 24 Hours Adequate Therapy should Resolve the Crisis within 6 Days
Continued
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FORMULA TS 41668 - 24 - 6
Practical Guidelines of Thyroid Storm Treatment
(Clinical Experiences : Tjokroprawiro 2002-2005)
21
This Formula should be given by a SEQUENTIAL MANNER 4 Loading Dose 400 mg PTU or 40 mg Methimazole Orally Maintenance : 100-200 mg PTU or 10-20 mg Methimazole Every 4 Hours Minimally, 1 Hour after PTU or Methimazole, and then Lugol can be given Lugol's Sol. can be given 6 gtt / 6 h (6 drops Every 6 Hours) Or, Sodium Iodide 0.25 g IV Every 6 Hours Oral Propranolol (Empty Stomach) can be given 10-40 mg Every 6 Hours Or, 1-3 mg/dose slow IV Propranolol, not to exceed 1 mg/min, and Repeat in 2 min, if needed Hydrocortisone 100 mg IV Every 8 Hours Formula 6.30 - 12.30 - 16.30 Or, Dexamethasone 2 mg Orally, Every 8 Hours Continued
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1 6
6
FORMULA TS 41668 - 24 - 6
Therapeutical Guidelines of Thyroid Storm Treatment
(Clinical Experiences : Tjokroprawiro 2002-2005)
22
This Formula should be given by a SEQUENTIAL MANNER 24 Clinical Improvement should occur within 24 Hours 6 The Crisis should be Resolved within 6 Days Special Attention : 1 Adequate Therapy has reduced Mortality from 90% (in the past) to 20% 2 The Precipitant is often the Cause of Death 3 Sympathomimetic Drugs fe. Pseudoephedrine and Amiodarone are : Daily Used Precipitants 4 Lugol's Sol. should be given After Meal , whereas Propranolol is better be given in Empty Stomach 5 Plasmapheresis, Peritoneal Dialysis, Cholestyramine or Colestipol 20-30 g/day, Chlorpromazine 25-100 mg I.M can be attempted if Patient is Seriously Ill. 6 ASA should be Avoided (!!)
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23
Go - T - TP
FORMULA TS 41668 - 24 - 6
Therapeutical Guidelines for the Treatment of Thyroid Storm
(Clinical Experiences : Tjokroprawiro 2002-2005)
24
Description
4-1-6-6-824-6 : Each shows Time of Treatment Period
4 1 6 6 8 24 6 Every 4 Hours of PTU-administration 1 Hour Interval between PTU (first) and Lugol (later) Administrations Every 6 Hours of Lugol-Administration Every 6 Hours of Propranolol-Administration Every 8 Hours of Hydrocortisone/Dexamethasone Treatment Clinical Improvement should occur within 24 Hours Adequate Therapy should Resolve the Crisis within 6 Days
ASK-DNC
25
26