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The endocrine emergencies most commonly discussed by EMS providers typically deal with diabetes mel-litus, a condition associated with malfunction of the pancreas or its hormones and improper regulation of the blood glucose level. It is important to recognize that there are many other emergencies that may be related to malfunctioning endocrine glands or hormones. These emergencies may produce acute life-threatening conditions that exhibit a wide variety of clinical presentations based on the gland or hormones involved. Some patients may not readily recognize, or may ignore, the slow and progressive clinical changes that are occurring and allow the disease to create an acute life-threatening condition.

Since EMS providers may be called upon to manage the patient experiencing this acute and potentially life-threatening condition, it is prudent for them to possess an awareness and understanding of other potential life-threatening endocrine emergencies, such as those involving the thyroid gland and its related hormones.

By Joseph J. Mistovich, MEd, NREMT-P, William S. Krost, BSAS, NREMT-P,

& Daniel D. Limmer, AS, EMT-P

Part 1: Hyperthyroidism and Thyroid Storm

This CE activity is approved

by EMS Magazine, an

organization accredited by

the Continuing Education

Coordinating Board

for Emergency Medical

Services (CECBEMS), for

1.5 CEUs.

OBJECTIVES

• Review anatomy of the thyroid gland

• Discuss metabolic disturbances

• Review emergency management of endocrine emergencies

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CONTINUING EDUCATION FROM EMS

endocrine emergencies

This article is the first in a two-part series addressing endocrine emergencies involving thyroid hormone disorders. The second part will follow in next month’s issue and cover conditions related to hypothyroid- ism. The section below on anatomy and physiology of the thyroid gland pertains to both articles. It will be important to review this section prior to reading the next article to completely understand the hypothyroid- ism conditions covered in part two.

BEYOND THE BASICS:BEYOND THE BASICS:

Part 1: Hyperthyroidism and Thyroid Storm

This CE activity is approve

by EMS Magazine, an

organization accredited by

the Continuing Education

Coordinating Board

for Emergency Medical

Services (CECBEMS), for

1.5 CEUs.

OBJECTIVESJ

• Review anatomy of the thyroid gland

• Discuss metabolic disturbances

• Review emergencyThis article is the first in a two part series addressing endocrine emergencies involving thyroid hormoneThis article is the first in a two part series addressing endocrine emergencies involving thyroid hormone

ENDOCRINEENDOCRINE EMERGENCIESEMERGENCIES

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ANATOMY AND PHYSIOLOGY OF THE THYROID GLAND

The thyroid is a butterfly-shaped endocrine gland located in the ante- rior neck just inferior to the thyroid cartilage (Adam’s apple). It consists of two lateral lobes that are connected anteriorly by a mass of tissue referred to as the isthmus. It can be easily pal- pated just below the cricoid cartilage. The size of the gland varies in indi- viduals depending on many factors. The thyroid gland is the largest pure endocrine gland in the body and has a very rich blood supply. Thus, when performing a needle cricothyrotomy, it is extremely important to ensure that the proper landmarks have been identified to avoid inadvertent lac- eration of the vascular lateral lobes or isthmus of the thyroid gland. If these are lacerated, an excessive amount of bleeding may occur, complicating an already dire airway situation. The gland may also be lacerated and bleed heavily from blunt or penetrat- ing trauma to the anterior neck.

The thyroid gland produces and secretes two distinct hormones: thy- roid hormone (TH) and calcitonin. Calcitonin is produced by a differ- ent group of cells within the thyroid gland, and is responsible for lowering the blood levels of calcium and stim- ulation of bone growth and develop- ment in childhood. It may also play a

role in reducing bone loss associated with starvation and in late stages of pregnancy when the fetus is compet- ing for calcium being absorbed in the digestive tract. Otherwise, the role of calcitonin in the healthy adult is not well understood; it may serve merely as a weak hypocalcemic agent.

The thyroid hormone is comprised of two different iodide-attached mol- ecules. Thyroxine, also known as tet- raiodothyronine or T4, makes up the majority of hormone secreted by the thyroid cells. It consists of four iodide ions attached to its molecular struc- ture. Triiodothyronine, also known as T3, is the other hormone secreted by the thyroid gland. It has only three iodide ions attached to it. Although only a small amount of T3 is secreted by the thyroid gland, approximately 10% of the TH secretion, a large amount is formed from the conver- sion of T4 through the removal of one iodine group by enzymes from the liver, kidneys and other tissues. Interestingly, though, T3 is primar- ily responsible for the thyroid hor- mone effect, which is primarily a very strong, immediate and short-acting increase in cellular metabolism.

It is important to review the trans- port, binding and concentration of T3 and T4 in the blood in order to understand a potential trigger for the disease process involving the thyroid hormone. Approximately 75% of T4

and 70% of T3 hormones attach to thyroid-binding globulins, also known as thyroxine-binding globu- lins (TBGs), upon entering the blood. A majority of the remaining T3 and T4 are attached to the plasma pro- tein albumin or a thyroid-binding prealbumin. Very small amounts of the thyroid hormone, approximately 0.3% of T3 and 0.03% of T4, are left unbound to diffuse into the periph- eral tissue. Thus, the only useable form of thyroid hormone is in an unbound form.

Both T3 and T4 bind to target tissue receptors; however, T3 binds much more readily and is about 10 times more active than T4. Equilibrium must be maintained in the blood between the amount of thyroid hor- mones bound to protein carriers and the amount being released into the peripheral tissue. Levels of T4 and the thyroid-stimulating hormone (TSH) play a major role in maintain- ing this blood level equilibrium. It is interesting to note that more than a week’s supply of thyroid hormone is found in the bloodstream.

Thyroid hormones affect many of the major organ systems and tissues within the body, with the exception of only the adult brain, spleen, testes, uterus and thyroid gland itself. Effects of the thyroid hormones are to:

• Maintain normal sensitivity of respiratory centers to changes in oxy- gen and carbon dioxide concentra- tions

• Maintain normal cell oxygen use • Maintain a normal basal meta-

bolic rate (BMR) • Promote calorigenesis (heat pro-

duction) by increasing the metabolic rate of cells

• Enhance the effects of the sym- pathetic nervous system

• Promote glucose metabolism, fat mobilization and protein synthesis

• Maintain normal adult nervous system function

• Promote normal cardiac func- tion to include rate and force of contraction

• Promote normal muscle devel- opment and function, and skeletal growth and maturation

endocrine emergencies

Patients with hyperthyroidism may experience tachycardia and an elevated systolic pressure. Pulse pressure may also be widened.

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• Promote normal gastrointestinal (GI) motility and tone, and increase digestive enzyme secretion

• Maintain hydration and secre- tory function of the skin.

Hypothyroidism, an insufficient number of thyroid hormones, or hyperthyroidism, an excessive num- ber of thyroid hormones, will cause metabolic disturbances that disrupt normal body function and have an impact on most or all of the aforementioned hormone effects. Hypothyroidism results in a decrease in hormonal effects on the body systems; hyperthyroidism increases or accentuates the thyroid hormone effects on body systems. Both condi- tions can lead to acute and poten- tially lethal emergencies.

PATHOPHYSIOLOGY Hyperthyroidism describes a con-

dition of excessive secretion of thy- roid hormone resulting from elevated

and inappropriate thyroid function. Thyrotoxicosis, also associated with an excessive amount of circulating thyroid hormone, results from the patient taking too much thyroid hor- mone (an exogenous source), or from an inflamed thyroid gland releasing too much stored thyroid hormone. Although these terms are often used interchangeably to describe an elevat- ed thyroid hormone level, they have different etiologies that affect long- term treatment. Hyperthyroidism and thyrotoxicosis typically describe the milder form of the disease process.

Graves’ disease, also known as diffuse toxic goiter, is the most com- mon form of hyperthyroidism. It is typically more common in women and usually occurs between the ages of 20 and 40. Graves’ results from an autoimmune condition that affects the function of the thyroid-stimulat- ing hormone, causing the thyroid gland to increase its production and

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The enlarged thyroid gland in Graves’ is typically diffuse and nontender to palpation. This woman also shows signs of exop- thalmos, which occurs when the tissue behind the eyes becomes edematous and fibrous and the extraocular muscles degenerate.

For More Information Circle 105 on Reader Service Card For More Information Circle 106 on Reader Service Card

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secretion of thyroid hormone and leading to hyperthyroidism.

Thyroid storm, also referred to as thyrotoxic crisis, represents a severe and potentially life-threatening con- dition. Although it is a relatively rare condition, occurring in only 1% to 2% of patients with hyperthyroid- ism, if left untreated, thyroid storm can be fatal, sometimes within days. It carries an adult mortality rate of 10%–20%. The pathophysiology of thyroid storm is not completely understood; however, it is thought that the excessive levels of thyroid hormone are not necessarily from the thyroid gland but from the conver- sion of bound-thyroid hormone in the blood to an unbound form. The unbound form becomes active and can easily enter peripheral tissue, producing a dangerous and possibly life-threatening hypermetabolic state and increased sympathetic nervous system activity. The patient may pres- ent with an excessively high fever (106°F), tachycardia, nausea, vomit- ing, diarrhea and hypotension.

Graves’ disease is the most com- mon underlying cause of thyroid storm. Other causes include taking an excessive amount of thyroid hor- mone (factitious hyperthyroidism) and administration of amiodarone, a rich iodine-containing antidysrhyth- mic agent that can have complex effects on the thyroid gland and hor- mone function. Other conditions that

may precipitate thyroid storm in the patient with hyperthyroidism include: infection, surgery, burns, trauma, cardiovascular events, preeclampsia or eclampsia, diabetic ketoacidosis, hyperglycemic hyperosmolar non- ketotic syndrome, insulin-induced hypoglycemia, pulmonary embolism, ingestion of thyroid hormone and drug reactions (Mellaril, Itrumil).

ASSESSMENT It is important to understand the

history and physical exam findings in a patient with hyperthyroidism. A patient who presents with life- threatening thyroid storm may have an undiagnosed history of hyper- thyroidism. Although hyperthyroid- ism and thyroid storm may present with a wide clinical array of signs and symptoms, clinical features of a hypermetabolic state and increased sympathetic activity are the most common. Key findings include agita- tion, weight loss, nervousness and palpitations. History findings include:

• Weight loss of approximately 15% of prior weight (often greater than 40 pounds)

• Cardiac palpitations • Nervousness • Anxiety, agitation, restlessness • Wide mood swings • Tremors • Chest pain in the absence of

cardiovascular disease • Dyspnea • Edema • Disorientation • Psychosis • Weakness • Diarrhea and increased bowel

movements • Increased perspiration • Fatigue • Intolerance to heat from the

hypermetabolic state • Abdominal pain. Physical exam findings include: • Fever (excessively high in thy-

roid storm) • Tachycardia (often 100–170 bpm)

that is out of proportion to the fever • Wide pulse pressure (40–100

mmHg) due to the increase in cardiac contractility (inotrope) with an eleva-

tion in systolic blood pressure • Warm skin • Diaphoresis • Dehydration (may be secondary

to diaphoresis and diarrhea) • Congestive heart failure • Thyromegaly (enlarged thyroid

gland) • Exopthalmos (protruded eye-

balls) • Stare with eyelid retraction • Atrial fibrillation, atrial flutter, or

premature atrial contractions • Tremors • Tender liver • Shock • Jaundice • Coma or obtunded mental

state. The enlarged thyroid gland in

Graves’ is typically diffuse and non- tender to palpation. If there is infec- tion or inflammation, the gland will present with diffuse enlargement and pain on palpation.

Exopthalmos occurs when the tis- sue behind the eyes becomes edem- atous and fibrous and the extraocular muscles degenerate. This is thought to result from the autoimmune dis- order associated with hyperthyroid- ism. In some cases, the protrusion is so severe that the optic nerve is stretched and vision is impaired. Severe eyeball protrusion may cause the eyelids to stretch and not close completely when the patient blinks or sleeps. This may lead to drying and irritation of the outer eye tissue, causing corneal ulcerations.

It is important for EMS providers to recognize not only the patient experiencing a thyroid storm, but also one who is exhibiting an array of signs and symptoms that are char- acteristic of hyperthyroidism. The hyperthyroid condition may progress rapidly to thyroid storm or conges- tive heart failure if not treated.

MANAGEMENT Thyroid storm is a life-threaten-

ing condition that requires immedi- ate emergency care and transport. Severe hyperthyroidism may also require supportive emergency care. Consider the following when man-

endocrine emergencies

Photo courtesy Bechara Y. Ghorayeb, MD

Surgery to remove an enlarged thyroid gland. The thyroid is normally a butterfly-shaped gland that lies in the anterior neck inferior to the thyroid cartilage.

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aging a patient with an acute and severe hyperthyroid condition:

• Establish and maintain a pat- ent airway. If the patient presents with an altered mental status or is comatose, it may be necessary to establish an airway by a manual maneuver, and potentially with a mechanical device, including endo- tracheal intubation, in severely altered mental states.

• Establish and maintain an adequate ventilation status. If the patient’s respiratory rate or tidal vol-

ume is inadequate, it is necessary to provide positive pressure ventilation.

• Establish and maintain ade- quate oxygenation. Assess the patient for evidence of hypoxia. Apply a pulse oximeter and deter- mine the SpO

2 reading. If there is

either clinical evidence of hypoxia or a SpO

2 reading of less than

95% on room air, administer a high concentration of oxygen via a non- rebreather mask. If the patient is exhibiting no signs of hypoxia or the SpO

2 reading is greater than

95%, supplemental oxygen may be applied via a nasal cannula at 2–4 lpm, especially if any dyspnea, chest pain or congestive heart fail- ure is exhibited during the history or physical exam.

• Provide continuous ECG moni- toring. Patients experiencing hyper- thyroidism or thyroid storm may present with cardiac dysrhythmias. Atrial fibrillation is common, espe- cially in the elderly. Patients may also experience atrial flutter and prema- ture atrial contractions. Traditional management of the ventricular rate control in atrial fibrillation or conver- sion to a sinus rhythm may not be effective until the thyroid levels have been managed.

• Initiate an intravenous line of normal saline. Patients may lose significant amounts of fluid from

excessive sweating and diarrhea. Aggressive fluid resuscitation may be necessary in severe cases.

• Initiate cooling measures if high fever is present. Remove the patient’s clothing, mist the body with water and fan aggressively. If antipyretic therapy is considered, avoid the use of aspirin. Aspirin may decrease pro- tein binding of thyroid hormones and increase the levels of unbound T3 and T4, thereby increasing the tissue uptake of thyroid hormone. Acetaminophen would be preferred

over aspirin since it does not have this effect.

• Expeditious transport. If the patient is experiencing a thyroid storm or a severe hyperthyroid con- dition, consider rapid transport to an appropriate medical facility that can initiate definitive therapy to decrease the thyroid hormone levels.

• Consider medications. Blockading the peripheral adrener- gic hyperactivity with beta blockers could be a critical factor in man- aging the thyroid storm patient. Propranolol (Inderal), the current beta blocker agent of choice, can reduce tachydysrhythmias, high body core temperature, tremors, restlessness, anxiety and palpitations. Another major indication for the specific use of propranolol is its ability to inhibit the conversion of T4 to T3 in the peripheral tissue. Keep in mind that T3 is responsible for the majority of thyroid hormone activity in the peripheral tissue. Contraindications to propranolol’s use include reac- tive airway disease, atrioventricular blocks, bradydysrhythmias, cardio- genic shock, hypersensitivity to the drug and congestive heart failure. It is important to note that heart failure in hyperthyroidism and thyroid storm is typically a high-output CHF, or heart failure due to tachydysrhyth- mias that may respond well to the

beta blocker therapy. However, use beta blockers with extreme caution if heart failure is suspected. The dose of propranolol is 1–2 mg intra- venously, repeated every 10 to 15 minutes until the symptoms are con- trolled. Be sure to follow your local protocol in managing the thyroid storm patient.

Another medication to consider is dexamethasone (Decadron), which also blocks the conversion of T4 to T3 in the peripheral tissue. Administer 2 mg intravenously. Again, it is impor- tant to follow local protocol when managing the patient.

CONCLUSION Even though the chance of

responding to a patient experiencing a thyroid storm or thyrotoxic crisis is rare, be prepared to quickly identify the severity of the condition and initi- ate rapid supportive emergency care and transport. Possessing a funda- mental understanding of the disease process will better prepare the EMS provider to rapidly recognize and manage this potentially acute life- threatening condition.

Bibliography Bledsoe BE, Porter RS, Cherry RA. Paramedic Care: Principles and Practice, Medical Emergencies, 2nd ed. Upper Saddle River, NJ: Prentice Hall Health, 2006. Guyton AC, Hall JE. Textbook of Medical Physiology, 10th ed. Philadelphia: W.B. Saunders, 2001. Marieb EN. Anatomy and Physiology, 2nd ed. San Francisco: Pearson Education, 2005. Martini FH. Anatomy and Physiology. San Francisco: Pearson Education, 2005. Marx JA, Hockberger RS, Walls RM. Rosen’s Emergency Medicine: Concepts and Clinical Practice, 5th ed. St. Louis: Mosby, Inc., 2002. Schraga ED. Hyperthyroidism, Thyroid Storm, and Graves Disease. www.emedicine.com/emerg/ topic269.htm.

Joseph J. Mistovich, MEd, NREMT-P, is a professor and chair of the Department of Health Professions at Youngstown (OH) State University, author of several EMS textbooks and a nationally recognized lecturer.

William S. Krost, BSAS, NREMT-P, is an operations manager and flight paramedic with the St. Vincent/Medical University of Ohio/St. Rita’s Critical Care Transport Network (Life Flight) in Toledo, OH, and a nationally recognized lecturer.

Daniel D. Limmer, AS, EMT-P, is a paramedic with Kennebunk Fire-Rescue in Kennebunk, ME. He is the author of several EMS textbooks and a nationally recognized lecturer.

Th yroid storm is a life-threatening condition that requires immediate

emergency care and transport.

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ENDOCRINE EMERGENCIES

1. The “Adam’s apple” is a commonly used name for the _____.

A. Thyroid gland B. Thyroid cartilage C. Cricoid cartilage D. Isthmus

2. The hormone secreted by the thyroid cells is made up mostly of _____.

A. Calcitonin B. Triiodothyronine C. Thyroxine D. Albumin

3. More than _____ supply of thyroid hormone can be found in the bloodstream.

A. One week’s B. Two weeks C. One day’s D. One month’s

4. Thyroid hormones affect many of the body’s major organ systems and tissues, with the exception of the _____.

A. Adult brain B. Spleen C. Uterus D. All of the above

5. The effects of thyroid hormone on body systems are accentuated by _____.

A. Calorigenesis B. Thyrotoxicosis C. Hypothyroidism D. Hyperthyroidism

6. According to the article, _____ is the most common underlying cause of thyroid storm—a potentially life-threatening condition.

A. Thyrotoxicosis B. Graves’ disease C. Hypothyroidism D. Excessive levels of T3

7. A patient who is suspected of having thyroid storm may exhibit all of the following signs, with the exception of _____.

A. Low-grade fever B. Congestive heart failure C. Tremors D. Atrial fi brillation

8. When examining the patient with suspected hyperthyroidism, the EMS provider would not fi nd _____ in the patient’s history.

A. Wide mood swings B. Edema C. Signifi cant weight gain D. Chest pain in the absence of

cardiovascular disease

9. _____ is a condition that occurs when tissue behind the patient’s eyes becomes edamatous and the extraocular muscles degenerate.

A. Thyromegaly B. Inotrope C. Exopthalmos D. Graves’ disease

10. Blockading the peripheral adrenergic hyperactivity with beta blockers can be a critical factor in managing the thyroid storm patient. According to the article, _____ is the current beta blocker of choice for treating hyperthyroidism.

A. Atenolol B. Propranolol C. Labetalol D. Betaxolol

11.The thyroid gland consists of two lateral lobes that are connected anteriorly by a mass of tissue, which is called the ____.

A. Thyroid cartilage B. Cricoid cartilage C. Fibrous tissue D. Isthmus

12. Concerning management of the patient with thyroid storm, which one of the following statements is not correct?

A. It is important to provide continuous ECG monitoring to assess for cardiac dysrhythmias.

B. If the patient’s respiratory rate is inadequate, provide positive pressure ventilation.

C. If fever is excessive, initiate cooling measures and administer aspirin to the patient until the fever subsides.

D. Assess the patient for hypoxia and administer oxygen as needed.