The patient has no prior history of a thyroid condition, so there's no way they have a thyroid emergency. Sam thyroid disease is like black mold in Florida. It's out there and if, you just happen to wait around long enough, it'll show up on things Hi everyone, and welcome back to another episode of EMplify. I'm your host, Sam Ashoo, and before we jump into this month's episode, I want to celebrate with you because EB Medicine is 26 years old.
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In on the other end of the microphone is Dr. TR Eckler back again, but much more afraid of the thyroid than I was just a few hours no doubt. Today we are talking about the. June, 2025, emergency Medicine Practice article on the emergency department management of patients with thyroid emergencies. This is Dr. Shaw and Dr. Chang who authored this article, and it is tremendous as always, but a little scary.
I will say, my common practice for thyroid emergencies has apparently not been aggressive enough. According to most of what I read today, which is disappointing and scary. what are your thoughts on that? did you have the same appreciation for thyroid disease as you do now? First, I wanna just note that this is a supremely timely article. I think we're coming into pretty scary hot American summer, with a lot of big storms chances for people to be without power in severe heat.
And my biggest takeaway was, you know, thyroid storm happens in the summer and, decompensated hypothyroidism, or. Mixed edema, coma, whatever you wanna call it at this point, happens much more often in the winter. So it seems to me that this is something I need to raise my alertness about seasonally and also like related to around disasters and power losses and things like that. But also, would agree with you, I think I left this article with a much clearer sense of how to manage it.
And a much greater fear that it's really challenging to make this diagnosis. And you have to have a high alert, and you always wanna be, even if you're not sure, you're wanting to pitch this to your admitting team and say, I think that this is where this is headed and therefore I think we should go this way with treatment. What do you Yeah. that's a, that's a great point and a great summary. Really. This article is on the polar extremes of thyroid disease.
We're talking about decompensated hypothyroidism, PS that used to be called mixed edema coma, and I was unaware of the terminology change. It just makes me old. So, decompensated hypothyroidism is now. The correct term, which is a pretty rare condition usually found in the elderly. You know, more prevalent in Women Peak, somewhere like in between ages 60 and 85, and like you said is more common in the winter months. So up to 90% of those presentations are in the winter. And then.
On the polar extreme opposite is the thyroid storm. So that's the most extreme version of hyperthyroidism or thyroid toxicosis, which generally presents or peaks in the summer months, is more rare. So we're talking like, you know, four to five people per a hundred thousand, in hospitalized patients, and even more rare than that in the general population.
But just as alarmingly worrisome when it comes to their presentation in the ed, I. And I would say that the one thing I took away from this article that was the most alarming was how many other things mimic these conditions or how many other things can complicate these conditions. The differential diagnosis there is quite long. Table two is fantastic in the article, but you know, decompensated, hypothyroidism, the differential for it is everything from acute.
Mi to carbon monoxide poisoning to encephalopathies and hypercarbia, and then all of the derangement that come from the disease. Things like hypoglycemia, hypothermia, altered mental status. And then there's the mimics as well, like sepsis and stroke. And so it can confound so many diseases.
It can be associated with so many diseases, and it has its own presenting symptoms, It seems like if you've got someone who's not at their normal baseline for any reason, you should be checking a TSH on them, just as routine practice, if they're in the geriatric population, A hundred percent and also cardiac patients, and I feel better that I've been doing that a lot in my practice and I felt like I was starting to wonder if
maybe I too aggressive and now I feel pretty confident that I'm fishing in the right ponds for the right kind of fish that I need to worry about having bad Yeah, Can I have a brief, just 10 seconds for a history of medicine appreciation mixed edema The history of medicine by TR Eckler. history of medicine, corner, mixed edema, coma. The mixed edema comes from Greek meaning mucus and swelling.
Because it's referring to the deposition of mucopolysaccharides that would go into your dermis when you develop mixed edema coma, which is why you get non-pitting edema these patients. So if you notice that they're having edema, if it's not pitting, you need to worry that this is more mixed edema coma, because they're depositing mucopolysaccharides in their dermis. First treated successfully in 1891 by a British gentleman named George Red, Maine Murray.
diagnosed a 46-year-old lady with the disease and treated her with sheep thyroid extract, successfully managing it for another 28 Wow. That's pretty cool. And there it is, ladies and gentlemen. The History of Medicine out a little history for mixed edema, That's good. That's actually very helpful. Yeah, the, the word mixed edema has always been kind of a. quandary to me, but that helps very much and kind of fits with the symptoms. It makes sense. Swelling, Mucus swelling. non-pitting. Excellent.
When it comes to those decompensated hypothyroidism patients, we mentioned earlier, the older population, like 60 to 85 more prevalent in women, and in patients who are poorly controlled on their thyroid supplements. So even if they have a known history of thyroid disease, you should especially be concerned about those patients because stuff happens and they stop taking their medication. They run outta money. They run outta medication. They can't get to the pharmacy.
And then on the other polar extreme is the thyroid storm patients and their differential diagnosis. Is equally as broad. So again, in that table, two things like drug withdrawal from opioids, alcohol and benzodiazepines, especially in this population, which actually happens to be a younger population.
We're talking about people in their forties where this is generally presenting, things like heat stroke because they're gonna be hyperthermic and altered hypertensive emergencies because they're gonna be tachycardic and hypertensive, hypoxia, psychiatric disease, anxiety, panic attacks, and psychosis. Interestingly, it's in the differential, but all of those can be caused by thyroid toxicosis. So really, if, if this is present, you're gonna go get those thyroid studies.
And then sepsis and tachycardias and dysrhythmias and atrial fibrillation, all of that stuff is in the differential. But again, it's concomitant to disease and it can be causal so your thyroid toxicosis can cause all of these things, or all of these things can alter your thyroid metabolism and push you over into thyroid toxicosis and give you the thyroid storm. And I will add that all of this talk is because of the significant mortality of these diseases, which was also surprising for me.
So the decompensated hypothyroidism has a mortality of 26 to 50%, especially in those higher risk patients, especially if they have cardiac complications or hypothermia or need mechanical ventilation, their mortality is terribly high. And then on the thyroid storm side. They have a mortality up to 25%, which also increases the more organs are involved and the more the central nervous system is involved.
So just such high mortality around these cases that it underscores the need to make a diagnosis and make it early. And I think as we're getting into this, making that diagnosis is challenging. And it's something that it seems like every, you know, decade, a new organization really tries to take a stab at trying to figure out what should be the diagnostic criteria, how do you define this? And it's not something where anyone's had a lot of success yet, so. Yeah, that's a great point.
And Table One nicely summarizes all of those guidelines dating all the way back to 2011 from organizations like the American Thyroid Association and the American. Task force for thyroid hormone replacement and the Japanese Thyroid Association means so many different organizations and so many different guidelines. Again, the authors did a great job of trying to synthesize all of that in this article. When it comes to the pre-hospital evaluation, pre-hospital side is pretty much the same.
It is, identify the vital sign abnormalities, begin some kind of Stabilization treatment en route to the hospital. And if you can, I would think the most important part, if you can get the history that they're supposed to be on medication, like their thyroid supplement and they haven't been taking it, that is just tremendously helpful. I. Then once they get to the ed, well then we begin our history. And again, the polar extremes are gonna involve the same questions.
So for the hypothyroid patient, we're gonna ask, you know, are you fatigued? Have you had progressive lethargy? Has there been weight gain or constipation or cold intolerance? In the severe cases, is there a history maybe from a family member you're gonna get about mental status changes? Hypothermia? Has there been recent triggers like infection, trauma, stroke. Heart failure, GI bleeding, or recent surgery, all of those are triggers to push somebody into decompensated hypothyroidism.
And on the polar opposite side of that spectrum, thyroid storm, is gonna present really with a patient who's quite agitated. So you might get the history from family in this case, about increasing agitation, palpitations, and tremors. Maybe fever at home, maybe weight loss, heat intolerance. And then the same triggers we're looking for anything that might have pushed them over the edge, like infection, trauma, stroke, heart failure, GI bleeding, or recent surgery.
I found the medications to be really instructive in this area. I found that talking about lithium and amiodarone, I felt like I had a sense of those in my head. But talking about some of the new or chemotherapy agents, pembrolizumab, which I didn't know the name of from the generic, but that's Keytruda. Which I see cancer patients on all the time. And then nivolumab, which is Opdivo, which is also something that I'm seeing more and more of.
So that gave me some pause to consider this more in my cancer patients that are coming in that are fatigued and weak. And I think often we attribute that to their chemo or infection, but I'm now gonna start thinking more about it possibly being their thyroid IV contrast can induce either hypo or hyper, I don't think I had quite. been as worried about as I should one more reason to be a hater of Ivy Contrast, right. and a hundred percent agreed.
And then when you turn the page to thyroid storm, looking at anesthetics and aspirin, there's so much, you know, outpatient surgery and things that you've gotta then think, wait, how did they do the sedation for that outpatient surgery? What medicines could they have gotten? And then looking at aspirin, there's so much use of different aspirin. And BC powder and, and, just some of the wintergreen patches that people use for pain control these days.
It's just another thing that I'm gonna be a little more suspicious of and a little more likely to get thyroid testing and kind of pursue that a bit further. Yeah. Yeah, great point. And honestly, in an altered patient, you know, you, you might get levels anyway for some of these substances, but you don't know. You just don't know what they're taking. They don't know what they're taking. Half the time, my own family members tell me they're taking Tylenol.
They're taking, you know ibuprofen instead, or they're taking some aspirin containing product over the counter. They have no idea. They go, oh yeah, it's Tylenol. Like, oh, okay. Is it, acetaminophen on the bottle? Oh, no, no, no. It's, ibuprofen. And I'm like, that's, that's not Tylenol. So, I, I always like nod and then I ask 'em to send me pictures. I'm like, is there anybody yes, there anybody that could like, just take some pictures of your medicine bottles in case EMS hasn't already yes.
of times they do tend to bring the medicines with them, which I, I find super helpful. But if it's always one of those things where if you can show me that or show me what your medicines are, or now if I can get it from the pharmacy records, it makes a big difference to be like, what about that? Yeah. Yeah. Really.
And you know, if you walk into a cabin full of medicines and pull out the phone, you're the, the friendly paramedic, just take a quick snapshot of it and show it to us when you get to the er, you know, or stick it into chat GPT and go identify all the medications in this photo and just get a list and go, oh, okay. You know, I, I. That There we are. Oil of Wintergreen. Who knew? So yes, lots and lots of triggers and medications. A very important one.
And Amiodarone really is not your friend in this scenario. It can cause either one of these, on the spectrum and, indefinitely. I. Aspirin, who knew aspirin? And then physical examination. When we're talking about the decompensated hypothyroidism, we're talking about things like bradycardia, hypotension, hypothermia, hypoventilation, slow respirations, or braa, lethargy, confusion. Status epilepticus, which is interesting.
That's not one I had associated with the decompensated hypothyroidism before. And things like, delayed deep tendon reflexes, cool skin non-pitting edema, as we heard earlier in the tr ular historical corner. And slowed speech with some ataxia. Really? So in your, in your geriatric patient, you think they might have Parkinson's or something. They actually have decompensated hypothyroidism. I always think in physical exam, I try to look for pacemakers, I try to look for surgical scars.
I think a neck surgical scar that suggests their thyroid is missing is just a really great thing to notice. 'cause even if they say, I don't have problems with my thyroid, you can be like, what's Yeah. they can be oh, well there was a nodule or something. So they took something out. It's oh, Yeah, yeah, that's some Sherlock Holmes, level physical examination right there where you go.
Ah, I see you're presenting altered in status epilepticus with a history of, having increasing weakness in lethargy at home, and you have a scar across the bottom of your neck. I have diagnosed you with decompensated hypothyroidism. Unfortunately, I missed the sepsis and forgot to start you on antibiotics. Right.
So don't forget the concomitant diseases and then examination findings with thyroid storm, are gonna be things like fever, tachycardia, dysrhythmias, like atrial fibrillation, hypertension, hyperreflexia, goiters. So if you're looking at the neck and there is no scar, but they have a goiter, gastrointestinal complaints, nausea, vomiting, diarrhea, stomach cramps, jaundice, and proximal muscle weakness.
So in the, in the very, extreme cases, you might see any one of those findings on physical examination. I always feel like I notice the exophthalmos like Oh yeah. Yeah. Like that's always the one that that kind of tends to jump out at me and, and help me not, you know, forget to order the Ts h but now that I'm ordering TSH on anybody that's a little confused or a little anxious or a little sick looking, I'm feeling better about making sure I've got all the levels I Yes, yes.
And if you're listening to this and you're not familiar with that term, exophthalmos, that is, where , their eyes just appear so big that their eyelids can't even close all the way over them. It's a startling examination finding, associated really with hyperthyroidism, but definitely should be present in these kinds of cases. And then we're moving on to. Laboratory analysis. So you have some history, you have a suspicion, and that's really the crux.
If you take away anything from this article, it is, you should have a healthy suspicion for both of these disease processes in someone who is at risk by age or by a recent history. And so if you can just even get to that point, the laboratory portion of this really isn't all that complicated. If they're on the decompensated hypothyroid spectrum, they might have associated hyponatremia and hypoglycemia.
And you're still gonna send your standard labs and liver functions and electrolytes, but you will be adding things like A TSH, and most labs nowadays will do a reflexive t four, or free T four even, if the TSH comes back abnormal. So that's probably an order already built into your emergency department order catalog. And on the other side, with the thyrotoxicosis, you might see things like hypercalcemia, hyperglycemia, elevated liver enzymes that.
May prompt you, you know, when you see jaundice on the exam, that may prompt you to go get those liver functions. And then similarly your TS, H and, and a free T four. Now interestingly, the authors did make the point that in the acute phase. Some of these thyroid hormone levels may not be helpful, especially in the decompensated hypothyroidism category.
They may still appear normal and they're more a reflection of recent history than they are of this moment right now, which again, I have to admit was new to me because I'm accustomed to seeing this and going, oh, okay. You know, the TSH is high, your T four is low, you're hypothyroid, or you're critically hypothyroid. Your TSH is way high up in the hundreds and your T four is completely undetectable. That is not the case, which unfortunately adds a lot of gray to these cases.
So you can have the clinical suspicion and have the history and then get the labs and go, oh, these labs aren't as bad as I thought, and then get completely distracted and not treat the patient. And a, the authors did a good job of dissuading that thought process and saying even if these labs are not as bad as you would think, especially in the hypothyroid patient, don't let the labs detract you from actually treating decompensated hypothyroidism.
And I think to your point, when your suspicion's high, you press through, like you don't wait for the reflex free T four, you lead by ordering the TSH and the T three and the T four, so that the sooner you can, the sooner you have more information to then help your, admitting team, your ICU team, everybody to have the most information possible and then you can say, Hey, I got all those labs before I gave the first dose of T four.
So those were numbers that were there before I started my treatment with that. Or I loaded with any steroids or anything else. There is a pretty good section in the beginning part of this article about just the physiology of thyroid disease and how it involves the hypothalamus and the pituitary gland, and we won't get into all that, but just know that if someone has severe adrenal.
Insufficiency or pituitary gland disease, all of those can be also causes of thyroid disease and this kind of presentation. So you're gonna broaden your laboratory testing a little bit. Random cortisol levels are recommended to test for adrenal insufficiency in patients who have decompensated hypothyroidism. When we get down into treatment, we'll talk about giving an initial dose of steroids to these patients anyway.
And so, it's definitely in the differential, arterial blood gas measurements, looking for hypercarbia testing for hypoxemia. If there's a concern or your finger saturation monitors not picking up, you're gonna want something more dependable. And then keeping that testing broad. So sepsis is in the differential. You're gonna get your cultures, you're gonna get your, lactic acid, and if they're presenting with altered mental status, you're gonna get your scan of the brain.
You're gonna consider things like lumbar puncture and meningitis in your differential. and then for cardiac testing, like you mentioned, especially in your MI patients or if they have dysrhythmias or EKG findings, you're going troponins and go down that route as well. So it's a big blanket of laboratory testing we're looking at. And the same with the hyperthyroid or the thyroid toxic patients, they're at risk for the same thing.
So you're looking at EKG telemetry, you're getting all of those labs in the ABG. You're looking for things like metabolic acidosis that is associated with this, looking for triggers. Interestingly, there is this Burch-Wartofsky score. You ever used that before? I haven't, but I think I would be more interested in it as selling it to. This is the reason we need to go to the ICU because our score is so high on the, I like their abbreviation. The BWPS Yeah good short acronym for your score.
It sounds serious. it's available in MD Calc, so if you're user, just go look up BWPS or type in hyperthyroidism. But it's a scoring system that gives you a number for thyroid storm, and that number correlates to, classifying their risk.
And so if their number is above a certain cut point, which is 45 or higher, that's consistent with thyroid storm and those people are at high risk and therefore need that more intensive monitoring, if it's not already obvious from their presentation, you can use that as a little bit of extra push to help justify the diagnosis.
Table five is a great breakdown of what to expect from your TSH free, T four in total, T three in the different states of thyroid disease being normal, all the way to hypo and hyper. And we don't have to get into all that. Just know that it's a reference and you can look that up if there's a question about it. if it's not obvious from looking at the labs, then that will help you interpret that. And then we get into treatment. So treatment depends on which side of the spectrum they're on.
Certainly both of these categories of patients are going to the ICU. Your decompensated hypothyroidism and your thyroid storm are both critical patients. They're all going to the ICU. I really liked their introduction to this, like looking at stabilization and treatment as, when you look at these patients, you need to think about oxygenation, ventilation, and perfusion because this is a disease that affects their entire body, not just their hormone levels. And I found it to be really.
humbling how much I needed to consider the whole picture and really think about their ABCs and what I was gonna need to do to try to stabilize them from an overall systemic standpoint while I was managing their endocrine emergency. Yeah. Yeah, that's a great point. So, you know, the basics count and you have to support all of their organ systems. That's excellent. When it gets down to targeted therapy for your decompensated hypothyroidism patient. You've got some options.
Obviously if they can take something orally, you can start replacing thyroid that way, but IV replacement is available. Most places have IVT four available. there is an interesting distinction there between IV T four and IVT three. The T four gets converted to T three in the body and you can give IVT three. But there is some question there. I thought the authors did a good job of discussing this as well.
there is some question about whether or not that comes with a higher incidence of side effects. You know, things like dysrhythmias and other abnormalities. and the dosing is a little bit sketchy. and so you gotta be a little careful not to accidentally give somebody too much. there seems to be a suggestion in the literature that it might be safer to just give somebody Iiv T four. And that's probably honestly what you have available in the pharmacy anyway. So, the dosing there is pretty simple.
A loading dose of two to 400 micrograms and then a maintenance dose of 50 to a hundred daily. and you're just gonna give that one time in the emergency department to, you know, standard adult dose, start at 200 micrograms and work your way up, especially in the elderly. Give the T four ask endocrinology if they want to give the T three. There you go. Great. If you have endocrinology available to you, that's a great person to call early in this process.
Or if you're out in the rural places, that's a good consult to ask because you can often stabilize these patients out in the rural places with that first dose of medicine, and then you can see how they respond to it.
And if you can get the endocrinologist on the phone to help guide that treatment and escalate treatment if needed to be, I think that's enormously valuable for that patient that isn't necessarily sitting on the, you know, the doorstep of a tertiary academic center down the road from 'em. Yeah, yeah, great point. And then steroids. So again, for the decompensated hypothyroid patient, we do give dose steroids.
We're talking about a hundred milligram IV load of hydrocortisone, followed by 50 milligrams IV every eight hours. And hopefully they're long gone out of your ED at that point. But if not, that's something that needs to be continued, because of that association with adrenal insufficiency. This will combat that. It will help with hypotension. If they're sick enough to require pressors, it'll hopefully help with their response to pressors as well.
Interestingly, if they have decompensated hypothyroidism and you provide IV T four to somebody who's in shock without giving them the steroids, you can actually clinically worsen them. So it's something to keep in the back of your mind. Those two things should be going together in this critical population. With the antibiotics. absolutely. That's right. You're gonna be treating that septic shock.
You can certainly reach for pressors if they're in shock, but just know that they also need the T four and the steroids. So this is not to supplant the need for pressors. And then on again, the polar opposite side for the thyrotoxic thyroid storm patients, this gets a little bit more complicated just 'cause we have multiple categories of medicines, right? So we need something to block the symptoms that tachy, dysrhythmia and hypertension. We need something to block new hormone synthesis.
We need something to block existing hormone from being released. And then we need something to reduce the conversion of any hormone that's in their serum into T three. So all four of those things are four different categories to block the tacky dysrhythmias. We're looking at beta blockers. Propranolol is still the preferential treatment, and it can be given down in ng. So if you don't have it iv, you can give it orally, or you can give it enterically.
If the person's unable to take oral, put an NG down and give it that way. Or another option instead of IV propranolol, which I would say a lot of us probably don't have available to us, is IV esmolol, titrable quickly on, quickly off, as needed. If they end up having hypotension or some complication, that is certainly an option. And this patient is going to go to the ICU anyway. So just one more infusion.
And then blocking new hormone synthesis is your PTU, your propothyouricil, and your methimazole. And propothyouricil is the preferred agent. It's also the only one approved to give to a pregnant patient. So if you've got someone who's thyrotoxic, in thyroid storm and pregnant, this is the medication of choice also given orally and. Then to block the release of hormone that's already made and sitting in the thyroid gland, you're gonna give the iodine.
That's the saturated solution of potassium iodide or the SSKI. With the stipulation that that's given after you've already given somebody PTU. So you gotta wait , about an hour after you've given somebody the medicine to block new hormone synthesis before you go, giving them a giant dose of iodide, because that will block the release of the new hormone. But if you haven't given them the PTU, it'll just result in them making more thyroid hormone.
And then lastly, to reduce the conversion of T four to T three in the serum or in the peripheral organs, corticosteroids. So you've heard that already. We've already given that to the patient who was decompensated hypothyroidism. We're also gonna give it to the patient with the thyrotoxic disease. So that's four different medicines we're giving to the thyroid storm, the beta blockers, the ides, which is the PTU, the iodine solution.
And the steroid, hopefully in the right order, but this table does a good job. Table seven on page 11 of kinda walking you through that process. Definitely wanna follow some kind of guideline to remember how much and in what order to give all this in in the thyroid storm patient. Significantly higher dose of steroids in the thyroid storm. You're looking at 300 milligrams of hydrocortisone versus only a hundred milligrams for your patient that's got decompensated hypothyroidism.
So I think this is a good thing to basically have your plan, know what you're gonna do, you know, start yourself on this treatment plan, but then at that point you also call endocrinology and say, Hey, this is where I'm going. Anything else you wanna add or subtract? Especially if they know the patient, I think that's always a great time to get them involved. Yeah, great points there.
Rationale for the higher dose is because in, the thyroid storm patient, you are trying to prevent that peripheral conversion of T four to T three, which requires more steroids. We're not giving this for adrenal insufficiency, which is traditionally a lower dosing. So yes. Excellent, excellent point there. Aspirin.
We talked about aspirin already, but obviously if they're on aspirin or if stroke is in the differential, if you're entertaining this diagnosis, aspirin containing products can actually make things worse and can lead to displacement of thyroid hormone binding, and increase the serum levels. So kind of judicious use there, you're gonna have multiple specialties involved if you're entertaining a stroke as a possibility.
And so making that diagnosis more accurately becomes important because you, you may end up accidentally worsening their condition by administering something like aspirin, which again, just underscores the complexity of making this diagnosis. Interestingly, you know, patients who fail medical therapy for thyroid storm are going on to pretty significant labor intensive treatment.
We're talking about things like urgent thyroidectomy, or plasma pheresis, which has been helpful in, as a bridge to thyroidectomy for patients to kind of, sift the serum for t four and catecholamines and autoantibodies and toxins. So there are benefits to plasmapherisis, but obviously that's labor intensive as well, and hopefully done in the ICU. So those are kind of second, third line therapies beyond the medical, if the medical is still not working.
so looking at special circumstances and populations, think the biggest thing I took away from this was the airway considerations you have in these patients. patients that might have mixed edema of their tongue, their posterior pharynx. They can have compression of their trachea and their airway because of a goiter or because of a thyroid mass or something else that's in that area.
So I think that treating these airways as high risk from both a structural standpoint and possibly also from a physiologic standpoint. These people can be hard to ventilate, they can be difficult to intubate, and they basically are not gonna breathe as well leading up to it.
So you have to really be more fearful of and more cautious in making sure that you preoxygenate and that you're addressing their hypercapnea and you're reaching for BiPAP and other ventilator strategies earlier in order to support them while you're figuring out what you can do to stabilize them.
But I think you need to approach this airway with an appropriate amount of wanting to load the boat and making sure that if you're thinking you need intubate, that anesthesia or ENT are there because it's not something that you want to try to do in the ER by yourself to perform a crike on a patient with a large Hmm, yes.
I don't wanna have to do a crike anyway, but I can't think of anything more terrifying than having to do a crike on someone with a giant goiter exactly where I'm going to be cutting. That's just going to make things so much more difficult. So yes. Excellent, . And definitely something to be aware of in advance. Risk management pitfalls. This was a very helpful section to me. Not that it usually isn't, but I thought this really highlighted some things.
So I'm just gonna ask some of these questions. Like the lab said that the thyroid studies won't be back for another hour, so I waited for those results to start treatment Oh. if, if it was only gonna be an hour, that sounds great to me in modern emergency medicine, Sam, because let me tell you, the pharmacy ain't getting that medicine there in one hour. If I need some IVT four and IVT three, but I would tell you that I think.
As soon as you have suspicion for this, and as soon as you can confirm that either the patient's got a history of higher low thyroid and your suspicion's there, I'm trying to initiate treatment as soon as I can without necessarily waiting for the labs, but I think that that's always such a moving spectrum. You're just trying to do the best you can and get as much information as you can and move the ball as quickly as you Perfect.
And you know, practically speaking, if you know it's gonna be another hour before the lab comes back and you know it's gonna be an hour before the pharmacy gets you the medicine, just order it now and then if you don't use it, send it back. I mean, I get TPA out of the Pyxis all the time. I don't use it very much, but I like to have it Yeah. Yeah. Okay. Her decompensated hypothyroidism is so severe, I opted for T three instead of T four.
I think I would want an endocrinologist to tell me to do that because I think there's risks that come with that decision. And I think I would start with T four and then I would reach out to the specialists, especially as this patient's heading for the ICU and say, do you wanna escalate to T three or something else? And often they'll say, no, you've done a great job. Let's see what happens next. Exactly. Call me back at 10:00 AM tomorrow morning. I will see him in That's right.
Yes. And that's because that T three does have this, possibility of increasing cardiac dysrhythmias. So if you're gonna give it, make sure they're on the monitor and you're watching closely, but preferably just give the T four. I gave the patient a diuretic because the chest x-ray showed pulmonary edema. Now this one, you're gonna get that chest x-ray result back before you get anything else, right? Before a single lab has returned. Maybe your blood gas or your point of care testing.
But before you get any other piece of laboratory information, you've already seen the chest x-ray. You know the patient is hypoxic, maybe, and you're looking at this X-ray going, oh, it's edema. It's decompensated heart failure. They have tachypnea and tachycardia. Maybe they're hypertensive. It's a hypertensive emergency. I gave 'em a dose of diuretic. It seems reasonable.
As you and I have previously discussed, acute decompensated heart failure responds better to medicine to control blood pressure like nitros and. BiPAP and respiratory support. So if that's what the chest x-ray you're looking at, you treat them with the, treatments that have been shown to be effective in that first hour. And then I think you wait to see your labs and then I think you wait to get more information. And then I think you make the diuretic choice.
But I don't think leading with diuretics in the acute heart failure patient or the acute decompensated thyroid patient is the right Yeah. Yeah. And really the, thought process behind that is you're giving them something that's going to intravascularly deplete them, and this person is going to crash and become remarkably hypotensive. So even though they have pulmonary edema on the x-ray, if you wanna go ahead and start treating that, like you said.
BiPAP or some kind of positive pressure ventilation. And judicious use of IV fluids is actually indicated in the thyroid storm patient, even in the presence of pulmonary edema because they're intravascularly depleted. A very complex scenario. So make sure you're placing the calls for assistance there. Great moment for, bedside ultrasound too.
You look at their, IVC, you look at their heart, you look at their lungs, you see if it really does look like CHF, but I think you can take that one chest x-ray and use the next steps to get more information to help guide your treatment in a way that's safer and more effective for the patient. All right. Next. I suspected a diagnosis of decompensated hypothyroidism. Excellent. And I gave thyroid hormone replacement. Excellent. While waiting on the corticosteroids to come from the pharmacy.
I got a problem there, Sam. 'cause now we might precipitate more worsening of their condition by precipitating their adrenal crisis and making them hypotensive in a way that isn't gonna respond to pressors. So we give the triangle together. We suspect the sepsis, we give them the steroids, we give them the thyroid hormone altogether as soon as we Yes, yes.
Because if their decompensated hypothyroidism is coming from adrenal insufficiency and you spank those adrenal glands with more thyroid medication, it ain't gonna do squat for this patient. it might actually make them worse. It might precipitate even worsening adrenal deficiency. In that case, they need the steroids. So steroids. With the T four or just before, , She was hypothermic, so I placed a warming blanket and gave warm IV fluids. Any issues with that?
I think that warming blankets are okay, and I've learned that the bear hugger is always acceptable, but warm IV fluids sometimes can be a little too aggressive because either the patient doesn't want IV fluids or they don't wanna be warm that fast. So I would tell you to be cautious, especially in these patients with active rewarming as opposed to passive rewarming. That's right. That's right. Because passive rewarming, is a little bit slower.
The active rewarming can actually lead to peripheral vasodilation, and if they're hypotensive, it can even worsen that more so just gotta be careful with how rapidly we're making changes. Does the Bear hugger also have a bear cooler setting as we're heading into summer? That's just a, I wonder if now in the age of everything, you know, like everybody being into ice baths, does Bear Hugger gonna roll out a Bear Hugger 2.0? That can become a bear Why not? I mean, the tool.
ED is already like at 65 degrees just normally, right? So I mean. We are very worried about healthcare costs and very not concerned about HVAC That's right. emergency physicians That's right. I mean, I'm in there with my parca on in the trauma bay trying to resuscitate people, so why not, uh, The patient has a contraindication to beta blockers, so I have no option for rate control in the setting of thyroid storm. True or false? That's false.
I got a million ways I can slow your heart down, Sam, and I would tell you that always think that you need to consider all your options. Calcium channel blockers for IL and Diltiazem can be used for rate control in patients like Perfect answer. The patient has no prior history of a thyroid condition, so there's no way they have a thyroid emergency. Sam thyroid disease is like black mold in Florida.
It's out there and if, you just happen to wait around long enough, it'll show up on things Perfect. And lastly, she is hypothermic because it's winter and EMS said she didn't have the heat on in her home. 90% of decompensated hypothyroid happens in the wintertime. So yes, she could be cold, but yes, she could also have myxedema coma now named decompensated Exactly, yes, she could be cold and yes, she could have decompensated hypothyroidism.
So don't forget about your thyroid disease and that ladies and gentlemen. Brings us to the end of this June, 2025, wonderful emergency medicine practice review of management of patients with thyroid emergencies in the emergency department. Again, thanks to our authors, Dr. Sean, Dr. Chang. This was a fantastic article. It is packed with other stuff we didn't touch on. Just as a teaser, if you're a subscriber. There's a whole section on pregnant patients.
There's a whole section on neonatal hypothyroidism and thyrotoxicosis, how to handle that and recognize that in the neonate and a section on pediatric patients. So lots of information in here. I highly recommend you go read it and claim your CME. I enjoyed the section on subclinical hypothyroidism. As an ER doctor, that feels like more and more I'm getting a burden of primary care put on me to initiate treatment for people.
I thought that that was very instructive for me about when I shouldn't be starting thyroid hormone for the patients that come in with subclinical hypothyroidism. One more reason to go and read the full article, ladies and gentlemen. All right, and that's it for today. I'm Sam Ashoo, and on the other end of the microphone. Eckler, hoping you be safe and take your Synthroid. Amen to that. Be safe everyone. and that's a wrap. Thanks for joining us for this episode of Amplify.
I hope you found it informative, and I want to remind you that ebmedicine. net is your one stop shop for all of your CME needs, whether that be for emergency medicine or urgent care medicine. There are three journals, there's tons of CME, there's lots of courses, there's so many clinical pathways, all this information at your fingertips at ebmedicine. net. Until next time, everyone, I'm your host, Sam Ashoo. Be safe.