Differentiating Thyroid Storm from Sepsis

[Melclin]

So I understand that sepsis is a common woopsie on the way to a thyroid storm diagnosis.

I'm getting the impression that the presentations don't quite look the same, but I'm trying to nut out a nice clear description of the difference in presentations for exam prep, and I can't really seem to nail it down.

Is the heart rate likely to be a bit higher that you would expect if it were simply a reaction to hypotension in sepsis?

History of hyperthyoidism is obviously a big one but people with a history thyroid conditions are not beyond presenting with sepsis as well, nor are they beyond being unresponsive such that they cannot tell us about their recent thyroid operation.

 

[Aidey]

This is purely from experience, the one person I've seen in thyroid storm was much more manic/agitated/violent than anyone I have ever seen in sepsis. I've had plenty of septic patients that are confused and get combative, but this lady was 5 ft tall, 90lbs soaking wet and trying to take on 3 cops that were all twice her size.

If I remember right, someone in thyroid storm will have high BP, while someone who is septic is likely to have low BP.

Beyond that, I think differentiating without lab tests is going to come from the history.

 

[rescue99]

So I understand that sepsis is a common woopsie on the way to a thyroid storm diagnosis.

I'm getting the impression that the presentations don't quite look the same, but I'm trying to nut out a nice clear description of the difference in presentations for exam prep, and I can't really seem to nail it down.

Is the heart rate likely to be a bit higher that you would expect if it were simply a reaction to hypotension in sepsis?

History of hyperthyoidism is obviously a big one but people with a history thyroid conditions are not beyond presenting with sepsis as well, nor are they beyond being unresponsive such that they cannot tell us about their recent thyroid operation.

Isn't normal/hypertension the suspecting factor? Since DIC, fever, tachycardia, delerium and acidosis are common between the two, BP might be the only hint we'd get in the field. I would expect the blood pressure to be slightly high.

 

[rescue99]

This is purely from experience, the one person I've seen in thyroid storm was much more manic/agitated/violent than anyone I have ever seen in sepsis. I've had plenty of septic patients that are confused and get combative, but this lady was 5 ft tall, 90lbs soaking wet and trying to take on 3 cops that were all twice her size.

If I remember right, someone in thyroid storm will have high BP, while someone who is septic is likely to have low BP.

Beyond that, I think differentiating without lab tests is going to come from the history.

OOPS....Aidey beat me to it.

 

[mycrofft]

Saw one thyroid storm after blunt trauma and some sepses,

including two "toxic shock syndromes" from snorting crank into staph infected noses. (Not that uncommon; one was male).
The TSS pt's felt sick. The thyroid guy was alarmed at his elevated pulse and somewhat excitable.

We had another guy who was septic and we didn't know it, being a delerious sociopath he became abusive and uncooperative but not truly "hyper" because he didn't have the energy. (He did have a "large" abscess hidden up in the dome of his diaphragm and TB meningitis..I wonder what his HIV status was on post-mortem?).

What's going on is dependent upon the stage of the respective processes, and what else is going on in their lives, such as drugs, psych., and nutritional status.

For an off the cuff answer: energy is shot in sepsis, not in thyroid, before they collapse. After: septic BP should drop and thyroid stay high, although each may have a rapid pulse (one thready, the other strong; you guess which).

Another differentiation: alcohol or benzo detox, far more common than thyroid. A third would be an adrenaline-pumping pheochromocytoma. Oh, and an overdose of levothyroxine. A fifth is an Elavil OD....

 

[Melclin]

AHH the BP.

This is purely from experience, the one person I've seen in thyroid storm was much more manic/agitated/violent than anyone I have ever seen in sepsis. I've had plenty of septic patients that are confused and get combative, but this lady was 5 ft tall, 90lbs soaking wet and trying to take on 3 cops that were all twice her size.

If I remember right, someone in thyroid storm will have high BP, while someone who is septic is likely to have low BP.

Beyond that, I think differentiating without lab tests is going to come from the history.

Isn't normal/hypertension the suspecting factor? Since DIC, fever, tachycardia, delerium and acidosis are common between the two, BP might be the only hint we'd get in the field. I would expect the blood pressure to be slightly high.

I get the uber agitation part, but I was thinking later stage than that. On the topic of BPs, there was not actually any mention of the BP in the lecture, only that we might consider fluids for dehydration, so I figured a low BP maybe due to some kind hyper osmolar type kidney dysfunction... ++sympathetic outflow etc...I looking for a reason why ^symp outflow wasn't causing hypertension, but seeing as though it looks like it does..I spose problem solved. Which does make me wonder though why it can be mistaken for sepsis. Is there perhaps a late stage presentation.... around unconsciousness time, where the BP might drop?

Also my pathophys text says that vasodilation occurs to dissipate the extra heat of all the metabolism, which also got me to figurin' hypotension. I guess the heart really does kick it up a notch.

What would you expect a person's blood sugar to be? Is it elevated because of all this extra sympathetic and metabolic --> ^ gluconeogenesis and ^ glygenolysis, or is it depressed because all the metabolising that the body is busy doing chews it all up? Is there a pattern at all?

including two "toxic shock syndromes" from snorting crank into staph infected noses. (Not that uncommon; one was male).
The TSS pt's felt sick. The thyroid guy was alarmed at his elevated pulse and somewhat excitable.

We had another guy who was septic and we didn't know it, being a delerious sociopath he became abusive and uncooperative but not truly "hyper" because he didn't have the energy. (He did have a "large" abscess hidden up in the dome of his diaphragm and TB meningitis..I wonder what his HIV status was on post-mortem?).

What's going on is dependent upon the stage of the respective processes, and what else is going on in their lives, such as drugs, psych., and nutritional status.

For an off the cuff answer: energy is shot in sepsis, not in thyroid, before they collapse. After: septic BP should drop and thyroid stay high, although each may have a rapid pulse (one thready, the other strong; you guess which).

Another differentiation: alcohol or benzo detox, far more common than thyroid. A third would be an adrenaline-pumping pheochromocytoma. Oh, and an overdose of levothyroxine. A fifth is an Elavil OD....

I don't think I fancy working in your area mate

Pheochromocytoma was is on our list... too bloody obscure to be examinable I reckon...*grumble*. Thyroxine ODs we covered too. Alcohol and benzo detox I didn't think of, and I'll have to read more about. I had to look up Elavil, but we do cover TCA OD, although I've seen one myself and subsequently discussed it with an experienced medic, who said the presentation I saw was typical of the many he'd seen. None of which had the anticholinergic affects I'd expected or the ECG changes we'd learned about (just a altered conscious state, GCS 11, and a very mild tachycardia)...I spose maybe its something that takes a while to present.

 

[MonkeySquasher]

Now, I'm not entirely sure of my own statement. So if I'm wrong, please, just point it out and don't grind me into hamburger. =D

This is purely from experience, the one person I've seen in thyroid storm was much more manic/agitated/violent than anyone I have ever seen in sepsis. I've had plenty of septic patients that are confused and get combative, but this lady was 5 ft tall, 90lbs soaking wet and trying to take on 3 cops that were all twice her size.

If I remember right, someone in thyroid storm will have high BP, while someone who is septic is likely to have low BP.

Isn't normal/hypertension the suspecting factor? Since DIC, fever, tachycardia, delerium and acidosis are common between the two, BP might be the only hint we'd get in the field. I would expect the blood pressure to be slightly high.

The TSS pt's felt sick. The thyroid guy was alarmed at his elevated pulse and somewhat excitable.

For an off the cuff answer: energy is shot in sepsis, not in thyroid, before they collapse. After: septic BP should drop and thyroid stay high, although each may have a rapid pulse (one thready, the other strong; you guess which).

I agree with the above. Both will have elevated HR, N/V/D, fever. Sepsis should have a lower BP and, at later stages, worse mentation. However, the person in TS should, at the start, have a lot of energy, and be more generally hyperthermic than fever, as I understand it. Also, as I understand it, TS onset and progression should be MUCH more rapid than sepsis.

http://www.medicinenet.com/script/main/art.asp?articlekey=77774

 

[mycrofft]

Suspend the Meatgrinder!

Sounds good monkeyman.

Another differentiator: a hyper thyroid-oid mioght not let you keep EKG leads on him.

Saw a pt once, was arrested holding a gun to his temple in the middle of a busy street, knocked down with a baton gun..took TWO rounds to do it. Was dx as manic with psychotic, but closer look revealed pheochromocytoma AND hyperthyroid due to a nodule. Knocked down the thyroid with meds, addressed hypertension with meds...then they released him. Never heard from him again.

 

[8jimi8]

Everyone is forgetting that sepsis does not present with just one set of symptoms.

sepsis is a continuum.

Early sepsis will present with a fever, and excellent perfusion. The endotoxins circulating can cause dead heart tissue to contract. So these people will not present as your typical shock/sepsis, they have great pulse and b/p and often tachy in the 100s may have a fever >100.

It is late sepsis where you will see distributive shock and a low grade temps.

 

[MonkeySquasher]

Never heard from him again.

Yeah, now that he was more medically stable, he went and finished the job off.

 

[mycrofft]

Sepsis..

"Have you been sick lately".
"Why, YES!!".

 

[Veneficus]

missed this in all the confusion

Somehow in all the confusion of finals and being told what I don't know by some overzealous EMT Bs this post escaped me.

The most common cause of thyroid storm is infection in a person with a history of hyper thyroid.

In older people, Goiter is grossly apparent sign but may not present in children with a history.

Because of the nature, exothalmus is almost always present in all ages with long standing history.

In the event of a thyroidectomy (partial or from an undiagnosed hot nodule lower in the thoracic cavity) you might also see the relocation incision and scar usually near the wrist of the parathyroid gland.

Differentiating from early sepsis. (late sepsis seems apparent so i don't want to type it out)

The hyperpyrexia may be more at a level closer to a malignant hypertension than "a mere fever" It may be uncontrolled by NSAIDs.

The major mortality factor is arrythmia, that is what you must be on the alert for. What you have is a massive catecholamine release and of course the presentation you would expect to see from it, high BP, hyper alert/ activity/agitation, possibly seizure. Even jaundice without a history of liver disease.

If I was going to make a memory aid for early presentation: History/goiter, hyperactivity, High fever, high bp, arrythmia. (if not a lethal one, very fast, well above boarderline tachy) From lack of prefil, you may also consider similar symptoms from heart failure. (if they are not in secondary heart failure from the hyperthyroid history)

Hope this helps.

 

[Veneficus]

I meant

Exophthalmos (also called exophthalmia or proptosis)

One day I will learn to spell and type or be able to afford a medical spell check program.

Today is not that day.

 

[mycrofft]

Ruling out sepsis might be easier.

If not ruling out, then discovering and passing on that it's likelihood is low.

MANY hyperthyroid cases (slo-mo thyroid storm if you will) are missed because the initial s/s are often psych-like and masked with benzo's. A lot of these are people of advancing age, losing body mass, but thyroid Rx is not being regulated properly, either by the MD, or by the pt themselves. Over time, they may show mild signs of thyroid overload like exopthalmia, but that takes tie and never gets like the acute emergencies.
OD of levothyroxine due to intent or accident can also cause it, acutely, without the exopthalmia.

 

[Veneficus]

Over time, they may show mild signs of thyroid overload like exopthalmia, but that takes time

(hope you don't mind my adding the "m")

I understand the Exophthalmos is caused by a disorder of collegen synthesis because of the increased metabolism.

Like I said

"Because of the nature, exophthalmos is almost always present in all ages with long standing history."

(fixed my spelling too)

OD of levothyroxine due to intent or accident can also cause it, acutely, without the exopthalmia.[/FONT]

That is a really good point.

OD is also the second leading cause of thyroid storm.

Making it is important to consider a hx of hypothyroid (the most common cause being surgical removal of) as suspect as well.

I couldn't find anything about sudden thyroid storm that was not from an OD, undiagnosed/untreated thyrotoxicity or a neoplasm.

Because of potential anatomical deviation of or "extra" glands due to variations in embryo development, the thyroid or a hot nodule may be a palpable mass usually no lower than the clavical, near the midline. But as with all things in medicine, nothing is absolute and some patient will probably be happy to demonstrate their subclavical variation I'm sure.

The definitive dx is circulating a t4/t3 test, which isn't going to happen prehospital.

Based on the disease process, I would be more worried about an occult case of an undiagnosed child rather than an undiagnosed adult though. (which will probably add a little stress to the provider)

Another good point mycroft mentioned was misdiagnosing as psych. Like all patients with an altered mental status, be careful on your working dx. The potential seizure activity could also appear as a neurological cause or the jaundice might be mistaken for liver problems.

Hyperthyroid is a very good example of why it is important to be really careful with dismissing somebody as simply "drunk." As I am constantly reminded, "drunk people get sick too."

That creates the question of: " Are you going to put every intoxicated person on a heart monitor to rule out an arrythmia as it is primarily responsible for the mortality?"

How are you going to explain calling for a higher level of care in a tiered response?

 

[Melclin]

Golly, in my exam related brain haze I forgot about this thread. But thank you all, I had a much better understanding.

Just had my medical management exam. A big :censored::censored::censored::censored::censored::censored::censored: of an exam, predicatable short answer, so pleased with one of them: "explain the difference in presentation, pathophysiology and affected demographic of DKA and non ketotic hyperosmolar state - 10 marks" - had just the previous day drew a big flow chart on my whiteboard describing the differences.

Only a few non diabetes endo questions...presentation of addison's crisis and something about thyroid hormomes.

Anyways cheers guys, I'm sure this will come in handy on the road someday.

 

[mycrofft]

Back to...The Storm

As I hope I mentioned a few days ago, we had a minor case when a guy was running full tilt, slipped and fell head first into a trough urinal, slamming his anterior throat on the edge. His initial worry was he thought he was going to asphyxiate, but ice and oxygen helped. He was in C spine then cleared by local ER, who noted in their chem panel elevated thyroid (not elevated TSH). Over next three days he had an upswing in bp/pulse and affect was a little accelerated (not drunk-like), but after day three he returned to baseline with an interesting bruise. They were talking about propylthyrourocil (PTU) but he never became emergently hyper and recovered pretty fast. Good thing it did not cause a similar effect on the parathgyroids!

 

[mycrofft]

Congrats Melclin!

Good on you!

 

[Aidey]

Hyperthyroid is a very good example of why it is important to be really careful with dismissing somebody as simply "drunk." As I am constantly reminded, "drunk people get sick too."

That creates the question of: " Are you going to put every intoxicated person on a heart monitor to rule out an arrythmia as it is primarily responsible for the mortality?"

Slightly off topic, but the first thing you said is one of the reasons all drunks/intoxicated people get a CBG in my amb. It has saved my butt at least 5-6 times.

I do attempt to put the majority of my more intoxicated pts on the monitor and at least get a quick strip. Partially to make sure they are in an acceptable rhythm, and also because many of them aren't in good enough shape to give me a decent history, so it can give me a tad more info on the pt.

 

[Melclin]

Slightly off topic, but the first thing you said is one of the reasons all drunks/intoxicated people get a CBG in my amb. It has saved my butt at least 5-6 times.

I do attempt to put the majority of my more intoxicated pts on the monitor and at least get a quick strip. Partially to make sure they are in an acceptable rhythm, and also because many of them aren't in good enough shape to give me a decent history, so it can give me a tad more info on the pt.

Definitely....any altered conscious state gets a BGL in my book...seeing as though my book has yet to be published (being a student....extending the metaphor to far?) I'd prefer to be sure.

Good on you!

Haha, cheers, but I haven't passed yet. Had my practical exam today, I didn't pass, but didn't fail, it has to go to the subject head for approval. So while I have a thread commandeered, I'll pose the question and lay my fate humbly at the feet of the collective wisdom of the participants of this thread (no sycophany though ).

I had an anaphylaxis pt:

54 female, volunteered that she thought she was having a reaction to a new antibiotic she had taken shortly before calling. I briefly asked her a few more questions to clear up what exactly had happened, she had abdominal cramps and had just had diarrhoea. Severely short of breath, obvious erythema on the neck, face. Extremely anxious, BP was 90/I forget, Pulse 110, RespRar - 12 (I took that to mean that she was in such profound resp distress that her RR was trending down), speaking only in single words, Sinus Tach, Loud expiratory wheeze, GCS 15. Tried some 100% through the closed circuit, wouldn't tolerate it, so back to simple face mask. I called for intensive care early, and had my partner draw up adrenaline while I did the vitals after I saw the erythema and SOB. There was a pause after obs for my explanation of the situation to the examiner (exam technique), I got nebulised Salbutamol and Ipratropium setup took another pressure and took HR off the monitor, no change in BP, HR now 120. Got the adrenaline on board. Partner to get the bed. Took meds and hx, spoke with intensive care, decided it would be quicker to go to the nearest ED and went, obs 5 minutely.

I got canned for giving the adrenaline too early and not eliciting a proper history first. I replied that I thought the threat to her airway was paramount and that no information I elicited would change my management in anyway. He didn't agree, saying that I hadn't taken enough of an event history to show that it was anaphylaxis, and other information like a temp could have been helpful...."what if she had a chest infection and the wheeze was from that?" At that point I didn't argue further because I didn't want him in a bad mood when he referred it to the subject head, but that seemed like a :censored::censored::censored::censored: reason to me. Looking back on it now, I feel like I could have got the adrenaline on board earlier.

What do you think? This thread should be titled, "Help Melclin as he stresses through exam period".