Thyroid gland 有兩個急症：thyroid storm 以及myxedema coma。

Thyroid storm並不常見，偶爾可見於急診室，且不易診斷。對有thyroid disease的病人要憑“感覺“，一眼就要覺得此人something wrong。
病人可以正常工作，但personality不同，很少笑，看起來他的每天都是世界末日，沒什麼表情。
病人很亢進，nervous。
會有exophthalmos（凸眼），palpitation（心悸）。
很能吃（increased appetite）但很不胖。

Muscle weakness，手腳會tremor。
腳上有nonpitting edema。

Hyperthyroidism with a precipitating factor such as infection, surgery, or other intercurrent illness, post ¹³¹I therapy, discontinued ATD treatment.

就是說：病人有hyperthyroidism而不自覺，或是求醫方式不當，且合併有感染，經歷開刀等。或是突然停用antithyroid drug、以¹³¹I治療後（就如同開刀破壞組織，釋出大量激素），及其他較嚴重的疾病，如AMI等等所致。

Severe hypermetabolism characterized by fever 38 C to 41 C with sinus tachycardia and AF or other cardiac arrythmias. Acute pul. edema or anasarca with heart dis.
Profused sweating, extreme irritability, tremor, nausea with vomiting and abdominal pain----delirium to coma, convulsion.
Abnormalities of liver function and jaundice may be seen.

亦即：有維持於38到40度的高熱，不易控制。會有sinus tachycardia，atrium flutter，甚至atrial fibrillation。有時會合併有pulmonary edema。會有fatigue的現象，如大量出汗、躁動。嚴重時會昏迷，甚至convulsion。有時也會有肝功能不佳、黃疸。

Blood samples for serum T3,T4, not wait the results.
Serum cholesterol decreased. Abnormal liver function.

檢查是抽serum T3和T4，但結果通常不能立刻知道，所以診斷常要靠經驗、臨床症狀和基本知識。如要靠實驗室檢查又會來不及。再說，病人不多，實驗室常不提供serum T3 , T4的檢驗。另外可用的還有：膽固醇下降，肝功能不正常。

Specific treatment

1. ATD---PTU 600-1200mg initially, then 200mg q6h
2. Iodine---lugol solution, 30 drops qd.
3. Beta blocker---propranolol, 40-60mg q6h;2-10mg IV q6h.metoprolol for asthma p't, 50-100mg q12h
4. heart failure---reserpine 2.5mg iv qid. or quanethidine 50-150mg qd.
5. corticosteroids---hydrocortisone 100 mg iv q8h.
6. Supportive treatment:fluid and electrolyte; digitalis, diuretics, cooling blanket or sponge bath,O2,glucose.
7. Plasmapheresis for not response to conventional therapy.

• 在急性期時，可給iodine-lugol solution,30滴／天
• antithyroid drug--PTU，給的劑量很大，一天給到600∼1000mg，而一顆PTU有50mg。先給200mg/q6h，一直給到800mg/day。這是當病人一直都在thyroid storm stage時。
• beta-blocker：propranolol。有氣喘病史者則用metoprolol(beta₁-blocker)。
• 心衰竭者給reserpine。
• corticosteroid的劑量不大，100mg/q8h，所以每天300mg。
• 支持性治療：fluid & electrolyte；digitalis。
• 如給要方式不足以控制thyroid storm，就要用plasmapheresis將血液中多餘的thyroid hormone & TSH洗掉。

治療機轉：注意beta-blocker和thyroidectomy，PTU。

The mortality of thyroid storm is between 20 and 67 %.
The outcome depends on the criteris for diagnosis.
Poor prognostic signs are servere CNS involvement,CHF,abnormal liver or kidney function,acute abdominal complications(bleeding,perforation) and advanced age.

要是不治療，必死。治療過程中的死亡率也有20∼60％。其結果和受影響的器官有關，如CNS，肝臟，心臟，死亡率會較高，預後也較差。此外，越早發現，越早治療當然比較好。

A 62-year-old male married veterans was admitted to another hospital because of productive cough,body weight loss,palpitation of heart and shortness of breath for one week.
He was in mental confusion state, BT 38.2 C, RR 22/min, BP 150/60 mmHg, HR 120/min, irregular with GrIII(Grade III) systolic murmur over apex, hepatomegaly about 3 fb below RCM. Hb 14.1, WBC 18,110, N/L (neutrophil/lymphocyte)87/10. Urinalysis RBC numerous,chest X-ray,pneumonoc patch right lower lung.
Serum Alb 3.3,
cholesterol 75,
T.Bil. (total bilirubin) 5.2,
Alk-p 190,
GPT 1,157 / GOT 3,312
Creatinine 1.3
BUN 35
HBsAg(-)
six sets of blood culture were negative.
T3 142ng/dl
T4 11.1 ug/dl
TSH 0.74 uU/ml
He was treated with penicillin gentamycin,digoxin and furosemide and was transfferred to our hospital 3 days later.
On the first admission day, neck tenderness was found but LP(lumbar puncture) gave negative result.Because of high serum T3(494 ng/dl) and T4(16.6 ug/dl) 3 years ago, he was treated with lugol sol, PTU, inderal and hydrocortisone on the second day.However, repeated test of serum
T3 80 ng/dl
T4 5.3 ug/dl
T.Bil. 13.1
Alk-p 250
LDH 547
GPT 1,188 / GOT 584
The ATD was discontinued and was treated as a case of hepatic coma. He expired on th 5th admission day.
沒辦法，送CPC公審。

Anatomical Diagnosis
Grave's disease, diffuse toxic hyperplasia of the thyroid 50 gm , with clinical evidence of thyrotoxic storm.
Centtrilobular hemorrhagic necrosis of liver, advanced 645g
Congestion of G-I tract, spleen and adrenals, advanced
Focal myocardial necrosis, interstitial fibrosis and myocardial hypertrophy 390 gm
Bronchopneumonia, bilateral , advanced 1320 gm
Slight focal fibrosis and calcification of the mitral valve
Slight atherosclerosis fo aorta and coronary arteries
Chronic cholecystitis, slight focal interstitial fibrosis of pancreas and hyaline perisplenitis

甲狀腺變大，50克，和臨床相對，應是thyroid storm。當時臨床大夫有警覺到，但lab data之thyroid hormona偏低或正常。這是由於症狀太嚴重，正常推理應升高的T3,T4被拉下來。
Liver congestion，GI更嚴重。心肺亦有受影響，
由於臨床急診大夫不夠細心，給錯診斷，而腸胃科也跟著急診室，導致病人multiple organ failure而expired。
結論：再acute stage thyroid storm 的病人，若T3,T4被嚴重的symptom所拉低，應測free T4 & high sensitive TSH以確定診斷。

Exposure to cold during the winter months or in the cold climate.
Infection
Cardiovascular disease, CHF, CVA
Trauma, Surgery, GI Bleeding
Drug reactions, use of anesthetics, hypnotics

台灣少見。溫、寒帶則常見，多發生在窮苦人家。病人看來胖胖的，懶懶散散的，無精打菜，提不起敬。
本症的發生常併有：很冷的冬天、感染、心血管疾病。腸胃到出血、藥物，如鎮定劑，麻醉劑，大麻。

• Hypothermia(as low as 23.3 C has been seen).
• Hypoventilation and respiratory acidosis.
• Lethargy progressing to stupor and coma.
• Extreme bradycardia, hypotension
• Hyponatremia with SIADH.
• Hypoglycemia
• Skin dry, thick(myxedema), puffy face, coarse hair, eyebrows are missing especially in the lateral part.
• Delayed relaxation of the deep tendon reflexes.

明顯的低體溫，可低到23.3度。臉很乾、很後，如“泡芙“的臉。換氣不足、困倦、心搏徐緩、低血壓、低血鈉、低血糖。Deep tendon reflexes表現很慢。病人就是無精打采，測智商不會高。

1. Primary hypothyrodism:decreased T3,T4,elevated TSH, but normal TSH in pituitary hypothyroidism. The resulrs will not be available for emergency management.
2. Less specific lab. data
   1. arterial blood gas and pH---pattern of respiratory acidosis
   2. hypoglycemia
   3. hyponatremia, may approach 115 mEq/L
   4. EKG--sinus bradycardia, low voltage, PR prolong, ST-T change.
   5. Chest X-ray : pleural or pericardial effusion.
   6. Elevated SGOT,SGRT,LDH,CPK,cholesterol.
   7. Normocytic normochromic anemia.

Primary hypothyroidism：T3,T4降低，TSH升高。
Pituitary hypothyroidism：T3,T4，但TSH正常。
診斷要靠症狀，T3,T4 level對診斷幫助不大。或是上述less specific lab. data。

Sick euthyroid syndrome---severe ill from other than hypothyroidism. Low T3,T4,FT3,normal FT4,T3RU,TSH,elevated r-T3.
Very low total T4 levels with a poor prognosis.
Etiology : circulating binding inhibitor?
甲狀腺可能本身已有病變，所以前述病例可能即為sick euthyroid syndrome表現。
T3,T4低，FT4正常，TSH和r-T3會升高。T4越低，預後越差。

1. Large doses of iv L-thyroxine must be given. An initial iv 400 hg of L-throxine is followed by 50 hg daily.---
2. Hydorcortisone 300 mg is given in divided doses, then tapered over the next 4 to 5 days. (Cortisol measure prior to treatment).
3. L-T3, 50 ug iv followed by 25 ug q6-8h to a maximum dose of 100-125 ug within the first 24 hr. The maintenance iv dose is 12.5 to 25 ug q12h or 25 ug orally q8h.
4. No iv preparation is available, thyroid hormone may be given orally by an NG tube in a comatose p't.
   1. The initial oral dose of L-T4 is between 250 and 500 ug followed by a maintenance dose of 100 to 200 ug qd.
   2. The L-T3 initial dose 50 to 100 ug followed by 12.5 to 25 ug q6-8h.
5. Ventilatory support--CO2 retension

Modest fluid restriction (less than 1000 cc qd)--mild hyponatremia; Na less than 110 mEq/L or seizure---hypertonic saline
Gradual rewarming with a covering blanket.
Mild hypotension should be treated conservatively.

• L-Thyroxine(T4) iv, 400 ug，然後50 ug/day。小心此藥導致之cardiac ischemia, ventricular arrhythmias。
• Hydorcortisone 300 mg is given in divided doses，4-5天。Hypo-,hyper-thyroidism都可給cortisone（用於其他藥物無法控制時，一天給300 mg）。Cortisone對甲狀腺的作用多樣化；其功能高時給予抑制，少時給予補充。用hydrocortisone前要先抽血測cortisol level以決定劑量。
• L-T3 iv ，25 ug q6-8h ； maintain時給 25 ug /q8h.
• 若無T3,T4之 iv form, 則以 NG tube 灌T4 250 到 500 ug ，然後每天NG灌入50-100 ug, followed 25 ug/q8h。
• 初期支持治療：限制fluid，最好一天少於1000cc，以免heart failure。並要保持體溫。

診斷得早，補充一星期可好；拖很久都不補T3,T4，病人會expired。

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