THERAPEUTIC MISADVENTURE WITH A BETA BLOCKER DURING A THYROID STORM

Abstract

SESSION TITLE: Critical Care and Pediatrics SESSION TYPE: Global Case Reports PRESENTED ON: 10/10/2018 01:00 PM - 02:00 PM INTRODUCTION: Thyroid storm (TS) has a high mortality rates, whether treated 20% [2] or untreated 50%-90% [1,2]. Immediate goals are to decrease synthesis, prevent release, decrease peripheral action with beta blockers, support circulation and treat the precipitating condition (3). Caution against beta blocker is warranted in patients with heart failure, although it may be beneficial when tachycardia is a significant precipitant to decompensated cardiac function (4). We present a case of thyroid storm with right heart failure and exaggerated response to propranolol leading to circulatory collapse secondary to cardiogenic shock. CASE PRESENTATION: 48-year-old female with untreated hypertension presented to emergency for progressively worsening dyspnea, cough and diarrhea with elevated white count and fever. Treatment was initiated per sepsis protocol and PE was ruled out with contrasted CT. Shortly afterward, GCS deteriorated from 14 to 6 and she was intubated for airway protection. Lab work revealed an undetectable TSH with elevated free T4 and T3. Upon revaluation, her Burch-Wartofsky Point Scale was 95, elevated from 55 on arrival. She received glucocorticoids, propylthiouracil and oral propranolol. She developed bradycardia and cardiac arrest. Post ROSC echocardiogram showed right heart failure with flattened ventricular septum and EF of 45%. A second cardiac arrest ensued despite glucagon and transcutaneous pacing attempts. She was stabilized with crystalloids, vasopressors and bicarbonate drip. Central venous and bladder pressures were 34 and 26, minutes before a third cardiac arrest that ended with an emergency bedside laparotomy for decompression of abdominal compartment syndrome. Her hospital course was further complicated by coagulopathy, blood loss and renal failure requiring dialysis. DISCUSSION: The concept of thyrocardiac disease must be kept in mind when managing a TS. In long standing hyperthyroidism, the resulting cardiomyopathy is compensated by tachycardia and increased sensitivity to catecholamines [3]. This compensation depends on excess adrenergic drive to maintains adequate cardiac output. Failure to consider this led to our therapeutic misadventure. Current management of TS includes propranolol to lessen the adrenergic effect on the heart and to inhibit peripheral conversion of T4 to T3. This patient’s experience suggested that abrupt disruption of this compensatory state with beta blockade puts the body at risk for cardiovascular collapse. CONCLUSIONS: It is imperative to for clinicians to avoid beta blockers or use short acting beta blockers with extreme caution when managing TS Reference #1: Nayak B1, Burman K. Thyrotoxicosis and thyroid storm. Endocrinol Metab Clin North Am. 2006 Dec;35(4):663-86, vii Reference #2: Richard Carroll and Glenn Matfin Endocrine and metabolic emergencies: thyroid storm Ther Adv Endocrinol Metab. 2010 Jun; 1(3): 139–145. Reference #3: Singhal, A., & Campbell, D. "Thyroid storm." 2003. www.emedicine.com/ped/topic2247.htm (16 Dec. 2004) DISCLOSURES: No relevant relationships by Emmanuel Addo-Yobo, source=Web Response No relevant relationships by Nanette Bentley, source=Web Response No relevant relationships by Diana Trofimovitch, source=Web Response No relevant relationships by Karthik Vijayan, source=Web Response No relevant relationships by Gabriel Zaietta, source=Web Response