[Music] all right you guys welcome back to the last lesson in the series of lessons in which we've been talking about the endocrine system and particular these disorders which were often going to find ourselves taking care of with in the ICU the last two of these disorders that we are going to be talking about here today are gonna be the difference between our thyroid storm and our mix edema coma and my name is Eddie Watson and I'm gonna be presenting this last lesson for you today but before we begin with this if this is your first time to our channel and watching one of our videos and you'd really be interested in more of these critical care in-depth content videos such as this one then we invite you to subscribe to our channel below make sure though that you guys hit that Bell notification icon that way you'll be notified as soon as our new lessons become available to you I truly value the subscriptions the likes and the comments that you guys leave for us it really goes a long way to help support our channel and for that I do want to thank you guys alright so thyroid storm vs. mix edema coma well as you can see by the giant thyroid gland that we have here both of these are going to be disorders that are resulting from an inappropriate level of thyroid hormone and so before we begin to dive in and talk about these two different disorders let's talk a little bit about the thyroid gland and in particular thyroid hormone which it's responsible for secreting so essentially the thyroid gland is going to release the hormone that we call T 4 and T 4 gets activated into what we call t3 and this is the active primary form of thyroid hormone now both t3 and t4 are extensively bound to albumin something like 99 percent of it is down to the albumin and really our thyroid hormone plays an important role throughout our entire body the two most important things that it does is it controls our metabolism as well as our hormone sensitivity and like I said this is a far-reaching hormone that really has its fingers in all areas of our body and so when we find ourselves in situations where we have an inappropriate amount of this hormone it can cause all sorts of issues which we're going to talk about now now the first of these that we're going to start off with is something that we call thyrotoxic crisis or what's commonly referred to as thyroid storm an essentially thyroid storm is a severe form of hyperthyroidism and so here essentially we have too much of our thyroid hormone and this can really lead to a systemic decompensation and really if this is left to be untreated in 48 hours that this can lead to death so definitely a very serious complication that our patients can find themselves in and so let's talk about what it is that causes our patients to go in this so typically it's going to start off with our patients who have either an undiagnosed or an under treated Graves disease and so really Graves is an autoimmune disorder and what it does is it causes the thyroid to release too much of the thyroid hormone and so what we find in these patients is they have some sort of event that happens in this event such as a illness injury or even surgery will essentially start a cascade that leads them into this thyroid storm and so if we talk about this path though of what causes our patients to go into this thyroid storm there's really a couple theories about the causes one theory is that it's due to changes in how our thyroid hormone binds to albumin another theory is that we see changes in the thyroid hormone receptors on our target tissues and the third theory is that this is some sort of exaggerated response to sympathetic activity and so we're not quite sure which one of these or combination these actually is the determining factor and precipitating our patients into this thyroid storm but the end result is the same due to this excessive thyroid hormone that we're going to find our patients in a hyper dynamic and hyper metabolic state and ultimately that this is going to disrupt our major body functions and so these signs and symptoms that we would expect to see in our patient are going to be a result of this hyper dynamic hypermetabolic state and this is really characterized by a high fever and this can be greater than 104 degrees you're also gonna see things like tachycardia palpitations and arrhythmias you could also see altered respirations tremors delirium or even stupor or coma and so if we move on and talk about how we would diagnose someone with thyroid storm it's important to know that there's no specific lab test that can really distinguish between this thyrotoxic crisis from a just generalized uncomplicated hyperthyroidism so we are gonna check labs like our TSH our free t3 and t4 levels but other than recognizing that our patients have hyperthyroidism and seeing these signs and symptoms that that's for the most part going to be what we're gonna use to make this diagnosis that they're in this thyroid storm although there are some studies that show that you may have an undetectable amount of TSH when these patients are in crisis so we're not going to have any true diagnostic tests that we can do we're gonna need to look at these signs and symptoms as well as these tests that tell us that our patients have hyperthyroidism so now let's go ahead and move on and talk about our treatment options so definitely if we know or suspect that our patient is in crisis they should be managed in the ICU and our treatment of this is really gonna revolve around five main things first is going to be to inhibit the thyroid hormone production next is going to be to block the release of thyroid hormone third is going to be to antagonize the peripheral effects of thyroid hormone and then from there we're going to provide supportive care and last but not least and probably the most obvious is to treat the precipitating cause of this crisis so if we go up here and we talk about our inhibiting the production of the roid hormone we're gonna use these anti thyroid medications and there's really two main ones that we use the first of these is what we call methimazole which goes by the name tap is all and the other is a medication more easily referred to as PTU now PTU is the preferred medication due to its ability to inhibit the conversion of t4 into the active t3 in the periphery the problem with this is it is a high risk for injury to the liver and possible liver failure so it is very important to carefully use this medication now for the second form of treatment where we want to block the thyroid hormone release this is mainly because these anti thyroid medications don't have an immediate effect and so what we'll do for these patients is we'll give them some sort of inorganic iodine and what this is going to do is this is going to block the release of t4 from the thyroid now you can also use radiographic contrast and for patients who have that iodine allergy we can also give them lithium to do this but it does have worse side effects so again iodine is our first line of choice so now at this point we're working to inhibit the production of the thyroid hormone we've also used the iodine to block the release of the thyroid hormone and so now we also want to antagonize the effects of thyroid hormone out in the periphery and so again because of the inhibition of this production can take sometimes days to even weeks we really need to block the effects of t3 in order to minimize the injury to the organs as well as reducing the signs and symptoms of this adrenergic stimulation and so in studies they found that our beta blockers are gonna significantly reduce the mortality rate in these patients by as much as 20% now of the beta blockers propanolol is our drug of choice but you can also use things like esmolol or atenolol now when we talk about providing supportive care these are gonna be things like giving them stress dose steroids some sort of cooling either with a cooling blanket or ice packs as well as the fluid replacement to try and prevent dehydration especially in patients who have vomiting and diarrhea and just this elevated and sensible fluid loss and lastly like we said we want to treat that precipitating cause to prevent our patients progressing back into this state of crisis all right so that's our review of thyroid storm like we talked about this is a case of a severe hyperthyroidism that's been precipitated by some sort of illness injury or surgery pushing these patients into crisis we talked about not really knowing exactly how this process works but that ultimately we're gonna see our patients as a high level of thyroid hormone leading to a hyper dynamic hyper benda Moloch state causing the signs and symptoms that we see and then talked about the different pillars of treatment for these patients so now let's move on and talk about mix edema coma and this really is a life threatening emergency and in the case of mix edema coma on the opposite side of our thyroid storm that this is essentially a severe hypothyroidism and so ultimately what we're gonna have here is some sort of stressor that's going to increase our body's metabolism that's gonna lead to them depleting the thyroid hormone and ultimately leads them into crisis now this is something that we see more often and women as well as the elderly but it's important to know that this has a mortality rate of anywhere from 20 to 50 percent so it's a very serious condition if we find our patients in this and it's like I said a life-threatening condition and so let's talk about some of the causes so like we said this is gonna be in our patients with hypothyroidism with the addition of some sort of stressor and these precipitating stressors can include things like an infection or trauma certain drugs can also cause this things like our tranquilizers barbituates and narcotics and another thing that comes up more often in wintertime is going to be a cold exposure and so whatever these precipitating stressors are this leads to an increase in our body's metabolism thus ultimately depleting the patients store of thyroid hormone and so let's talk about some of the signs and symptoms that we'd expect to see in our patients with this mix edema coma now we're gonna see a hypothermia and this is going to be as a result of not having this thyroid hormone around leading to this decreased metabolism and we can see temps in these patients anywhere from 80 to 88 degrees and when you see this this really is a grave prognosis for these patients could also see hypoventilation [Music] hypotension bradycardia hyporeflexia this is as a result of these slowed neuron conductions you're also gonna see hyponatremia a generalized interstitial edema and this is where the term mix edema comes from is this diminish appearance that you're going to see and the reason for this is we have these accumulation of intradermal proteins that just pull the fluid out of our vasculature into these interstitial spaces in these patients you can also see a depressed consciousness and this can be part and due to the increase in our patients co2 level from that hypoventilation so now if we look at how we diagnose these patients and really our diagnosis here is going to be based on our labs and symptoms so again we're gonna check our thyroid function things like a CBC and a CMP you also want to check an ABG on these patients cortisol level and possibly even blood cultures to rule out some sort of infection you may also do other diagnostic studies like a chest x-ray EKG perhaps an ultrasound or a CT of the head although these are going to be primarily to rule out other disorders and possibly identify some of the signs all right and so lastly let's talk about the treatment that we have available for these patients now treatment for mix edema coma is really going to involve four things first is our hormone replacement next is going to be to correct our fluid and electrolyte balance third will be our supportive care and last but not least identify and treat the cause so for our hormone replacement treatment there is some controversy that exists over using just t4 versus t3 and t4 but ultimately we need to give them this thyroid hormone that they are lacking now when we're correcting our fluids and electrolytes we want to give them fluids if they are hypotensive and possibly using hypertonic saline for their hyponatremia now for a supportive care this is gonna really involve the most things that we're doing here these patients because of this hypoventilation and decreased consciousness that they may require intubation and mechanical ventilation they may also require temporary pacing if they have a symptomatic bradycardia we do also want to warm these patients either with warm blankets or a warming device we're also going to want to provide glucose for them as well as our stress dose steroids and this is really gonna be to help with our blood pressure as well as our glucose and then like I had already mentioned we want to identify and treat the cause that precipitated our patients progressing into mix edema coma alright so that pretty much covers what we're going to talk about here with mix edema coma like I said important thing to remember this is life-threatening with a pretty grave mortality rate for these patients this is a case of a severe hypothyroidism because our patients bodies are having an increased metabolism depleting those thyroid stores and leading them into crisis the signs and symptoms that we're gonna see are gonna be as a result of this lack of thyroid hormone to their body and like I said can be very serious we don't have any true defining diagnostic criteria for this we're just gonna look at our lab values as well as these signs and symptoms to diagnose them but when it comes to our treatment we want to make sure we're we're placing the hormone that they don't have we're correcting any fluid electrolyte issues that are going on truly support them through this and then ultimately we've got to find that cause all right so that is gonna wrap up this lesson looking at the differences between the thyroid storm and mix edema coma two very different disorders on very different ends of the spectrum but both relating to this imbalance of thyroid hormone hopefully with this lesson this has made things a little bit clearer between the differences between these two and what you would to see as well as the treatment options available and while these aren't very common again it is important to have this good foundation of of knowledge in the event that you do come across a patient that is in one of these crises and so with that said I do want to thank you guys so much for watching this is the last lesson in this series on the endocrine system and I really hope this lesson as well as all the past lessons that you guys found the information in there useful that it helped you to understand what's going on with these different disorders because these are things that you are going to see in the care of your patients and the ICU if you did find this video useful please leave us a like below as well as leave us a comment and let us know what you think these really do go a long way to help support our channel in these videos I'd also like to direct you to check out the last series of lessons that we did in which we talked about heart failure as well as another real popular video that we have in which we take a look at the basic proper order of draw for the lab tubes all right you guys thank you so much for watching you guys have a wonderful day