Hyperthyroid crisis in the elderly
Introduction
Introduction to thyroid hyperthyroidism in the elderly Hyperthyroidism crisis is called hyperthyroidism crisis. It is a serious complication of thyrotoxicosis and endangers the life of patients. This disease is not common, but the mortality rate is very high. basic knowledge The proportion of illness: 0.005% Susceptible people: the elderly Mode of infection: non-infectious Complications: arrhythmia heart failure shock
Cause
The cause of hyperthyroidism in the elderly
Stress stimulation (10%):
Most hyperthyroidism occurs with certain predisposing factors, mainly stress stimuli, such as acute infection, mental stimulation, trauma, surgery, acute myocardial (or other visceral) infarction, diabetic ketoacidosis, 131I radiation therapy for hyperthyroidism and surgery. Squeezing the thyroid is also a common predisposing factor.
A large amount of thyroid hormone is released into circulating blood (20%):
Some patients with hyperthyroidism taking a large amount of thyroid hormone can cause crisis; thyroid surgery, improper cessation of iodine and radioactive iodine treatment, the patient's blood thyroid hormone rises, causing hyperthyroidism, which supports the occurrence of this disease is Due to the sudden release of a large amount of thyroid hormone into the blood.
Increased free thyroid hormone in the blood (10%):
Infection, stress in other parts of the thyroid, etc., can reduce the concentration of thyroid hormone-binding protein in the blood, dissociation of thyroid hormones combined with it, and increase of free thyroid hormone in the blood, which may explain the incidence of some patients with hyperthyroidism.
Changes in the body's response to thyroid hormones (10%):
Due to the influence of certain factors, the organ and surrounding tissues of the patients with hyperthyroidism have reduced ability to adapt to excessive thyroid hormones. Because of this decompensation, the crisis is caused, and there are many systems in the clinical crisis. This view is supported by functional failure, elevated thyroid hormones in the blood, and no specific pathological changes seen during autopsy in some patients.
Increased adrenergic activity (10%):
Sympathetic blockade in animal experiments or in patients with hyperthyroidism, or taking antisympathetic or beta-adrenergic blockers, can improve the symptoms of hyperthyroidism, indicating that many manifestations of hyperthyroidism are due to increased thyroid hormones in the patient's blood. To increase the effect of catecholamines, hyperthyroidism, so excessive heat production is due to increased fat decomposition, thyroid hormone can directly or through the increase of catecholamines to break down fat, patients with hyperthyroidism use -adrenergic blockers, blood The increase in free fatty acid levels can rapidly decrease, and the clinical signs of hyperthyroidism are simultaneously improved.
Reduced clearance of thyroxine in the liver (10%):
Before and after surgery and other non-thyroid diseases, the reduction of eating calories can cause a decrease in T4 clearance. It has been reported that infections often involve more than 50% reduction in T4 clearance, which can increase the thyroxine content in the blood.
The reasons listed above may explain the occurrence of some hyperthyroidism crisis, but it is not possible to summarize all the mechanisms. Therefore, it can be considered that the occurrence of hyperthyroidism crisis is not caused by a single cause, but is caused by many factors.
Prevention
Elderly patients with hyperthyroidism crisis prevention
Third-level prevention
(1) Primary prevention:
1 For the immediate family members of patients with hyperthyroidism, regular thyroid function tests should be performed, and hyperthyroidism should be treated promptly.
2 multi-junction goiter mainly combined with clinical and subclinical hyperthyroidism, especially in the elderly with low iodine area, for this group of people, can give appropriate levels of iodine intake, if necessary, radioactive iodine treatment and surgical treatment, To prevent the occurrence of hyperthyroidism.
(2) Secondary prevention:
1 Improve the diagnostic level of atypical hyperthyroidism, timely treatment, and be alert to the atypical characteristics of the crisis to avoid misdiagnosis.
2 patients with hyperthyroidism should take systematic regular treatment measures to effectively control the condition, avoid mental stimulation, prevent and actively treat infection.
(3) Level 3 prevention:
1 hyperthyroidism must be prepared before surgery: before the operation must be fully treated with anti-thyroid drugs to symptom control, heart rate <80 times / min, T3, T4 in the normal range, start feeding 2 times before surgery, add iodine solution, each time 3 to 5 drops, 1 to 3 times / d, to reduce intraoperative bleeding, prevent hyperthyroidism crisis.
2 patients with hyperthyroidism treated with 131I, patients with severe disease should be treated with antithyroid drugs for 3 months, after the symptoms are relieved, the drug is stopped for 3 to 5 days, and then 131I treatment.
2. Risk factors and interventions
Hyperthyroidism is more common in middle-aged and elderly patients with severe hyperthyroidism. These patients are often significantly thin, with long duration and untreated or long-term irregular treatment. If you encounter some incentives to aggravate hyperthyroidism, it may lead to hyperthyroidism. Occurrence, common causes include:
(1) Infection: The most common, accounting for 40% to 82.8% of all incentives, among which bacterial infection is the most common, especially acute upper respiratory tract infection. The more severe the infection, the more likely it is to induce hyperthyroidism crisis, prevention and active treatment of infection. necessary.
(2) Stress: Extremely nervous, overworked, high temperature, hunger, drug reactions (such as allergies, digitalis poisoning, hypoglycemic hypoglycemia), heart failure, etc. can cause thyroid hormone to suddenly release thyroxine, causing hyperthyroidism Therefore, patients with hyperthyroidism should take appropriate rest, diet should be supplemented with high nutrition, high calories, including sugar, protein and vitamin B, etc., for those who are nervous, uneasy or insomnia, can give tranquilizers.
(3) Inappropriate anti-thyroid drugs: For example, some patients take iodine and suddenly stop using it. The original hyperthyroidism can be rapidly aggravated because iodide can inhibit the hydrolysis of thyroid hormone-binding protein and reduce the release of thyroid hormone. In addition, after 2 weeks of anti-thyroid drugs are discontinued, the hyperthyroidism may be induced due to the disappearance of thyroid drugs. Therefore, patients with hyperthyroidism should avoid the abuse of iodine. The anti-thyroid drugs should be treated for a long period of treatment, reduction and maintenance.
(4) 131I treatment: rare, hyperthyroidism patients with severe disease, severe thyroid enlargement, 1 to 2 weeks after taking 131I due to 131I destruction of thyroid tissue, a large number of thyroid hormones released into the blood in a short time may induce Hyperthyroidism, for such patients should be treated with anti-thyroid drugs, 131I after the condition improved.
(5) Surgery: Because the current hyperthyroidism patients generally have adequate drug preparation before surgery, the hyperthyroidism caused by hyperthyroidism surgery is rare. It is worth noting that patients with hyperthyroidism are not prepared for drugs because of other diseases. Intraoperative, postoperative need to be highly alert to the occurrence of hyperthyroidism crisis, if the hyperthyroid crisis occurs after 36h of surgery, often more than non-surgical factors such as infusion reaction, infection and so on.
(6) Others: If trauma, hyperthyroidism patients develop pregnancy complications during pregnancy, such as pregnancy-induced hypertension syndrome, hyperthyroidism with diabetes and ketoacidosis.
3. Community intervention
In recent years, China has implemented universal salt iodization, but with the increase of iodine intake, the incidence of thyroid disease has increased. Among them, the incidence of iodine-induced hyperthyroidism is the most concerned. Iodine is not only thyroid hormone synthesis. The raw materials can also enhance the antigenicity of thyroid tissue components, induce immune response on the basis of the original genetic susceptibility defects, and often occur after iodine supplementation in areas with iodine deficiency. The symptoms of hyperthyroidism are insidious, and the TSH measurement is lower than normal, which is helpful for early diagnosis. The prevention of hyperthyroidism caused by iodine can reduce the occurrence of hyperthyroidism. WHO recommends that the daily intake of iodine is 150g, urinary iodine. The median (MuI) should be maintained at 100 g/L. This criterion is based on alternative treatment for hypothyroidism. According to a 1997 sample survey, the median urinary iodine level in China has reached 354 g/L, and in some provinces up to 504 g/ L, the upper limit of safe iodine intake is currently inconclusive in the world, normal people have a high tolerance to iodine, and intake of 100-200 mg of iodine per day can be There is no response, but it is dangerous for some special populations to increase iodine intake. These special populations include residents of iodine-deficient areas, especially those with nodular goiter and thyroid nodules, with autoimmune thyroid disease. (AITD)) genetic background, therefore, the main measure to prevent iodine-induced hyperthyroidism is to strengthen the monitoring of urinary iodine concentration in residents after implementing the universal salt iodization policy, especially to strengthen iodine-induced hyperthyroidism. Urinary iodine monitoring in susceptible populations.
Complication
Elderly patients with hyperthyroidism crisis Complications, arrhythmia, heart failure, shock
The main complications are severe arrhythmia, heart failure, shock and so on.
Symptom
Elderly hyperthyroidism crisis symptoms common symptoms hyperthyroidism crisis irritability coma dry skin loss of appetite high fever nausea anxiety drowsiness skin pale
The clinical manifestations of senile hyperthyroidism are not typical, and clinicians have insufficient knowledge, so that it is difficult to diagnose in time when the crisis occurs, but the senile hyperthyroidism crisis has certain clinical characteristics.
1. Typical hyperthyroidism
(1) high fever: body temperature rises sharply, high fever is often above 39 °C, sweating, skin flushing, then sweating, pale skin and dehydration, high fever is a characteristic manifestation of hyperthyroidism crisis, is an important identification with severe hyperthyroidism Point, use general antipyretic measures are invalid.
(2) Cardiovascular system: the pulse pressure difference is obviously increased, and the heart rate is significantly increased. More than 160 times/min, patients are prone to various kinds of tachyarrhythmia, such as pre-systolic contraction, atrial tachycardia, paroxysmal and persistent. Atrial fibrillation, in which pre-contraction and atrial fibrillation are the most common, and heart enlargement and even heart failure are more common. If the patient has blood pressure drop, heart sound is weakened and heart rate is slow, indicating that the patient's cardiovascular system is in a state of severe decompensation. Cardiogenic shock has occurred, and many elderly people have only abnormal heart, especially arrhythmia.
(3) Digestive system: very bad appetite, nausea, frequent vomiting, abdominal pain, diarrhea, and some elderly people with prominent symptoms of digestive system.
(4) Central nervous system: mental disorders, anxiety, irritability, psychopathy, lethargy, and finally into a coma.
2. The threatened crisis
Due to the high mortality during the crisis, he often died of shock and heart failure. In order to rescue patients in time, the diagnosis of pre-crisis or threatened crisis is clinically proposed. The threat of crisis is:
1 body temperature between 38 ~ 39 ° C;
2 heart rate is 120 ~ 159 times / min, there may be arrhythmia;
3 loss of appetite, nausea, increased frequency of bowel movements, excessive sweating;
4 anxiety, irritability, crisis premonition.
3. Atypical hyperthyroidism
Patients with atypical hyperthyroidism or premature systemic failure, dyscrasia, often do not have the above-mentioned typical performance when a crisis occurs, but only one of the following systems, such as:
(1) Cardiovascular system: severe arrhythmia or heart failure such as atrial fibrillation.
(2) Digestive system: nausea, vomiting, diarrhea, jaundice.
(3) Mental nervous system: mental illness or apathy, stupor, extreme weakness, lethargy, slow response, coma, low response.
(4) The body temperature is too low, the skin is dry and sweat-free.
Examine
Examination of hyperthyroidism crisis in the elderly
Thyroid function test
Serum T3, T4, rT3 increased, FT3 and FT4 increased more significantly, but there is no boundary with no crisis, and thyroid hormone measurement results may be inconsistent in patients with hyperthyroidism. Some scholars believe that in crisis, The level of thyroxine in the blood of patients is higher than that of non-crithal hyperthyroidism. Some scholars have also seen that the thyroid hormone content of hyperthyroidism crisis is not significantly increased. Therefore, the determination of thyroid hormone in blood does not help the diagnosis of hyperthyroidism crisis. When the level of thyroid hormone is significantly higher than normal, it has a certain significance for diagnosis and prognosis.
2. Blood routine
No specific changes, such as the total number of white blood cells and neutrophils, suggesting the presence of infection.
Electrolyte
Because patients with hyperthyroidism are in a state of markedly high metabolism, high fever, vomiting and even diarrhea cause dehydration and electrolyte imbalance in most patients. Among them, hyponatremia is the most common, and there may be metabolic acidosis and hypokalemia.
2. ECG
Can display a variety of tachyarrhythmia.
Diagnosis
Diagnosis and diagnosis of thyroid hyperthyroidism in the elderly
Diagnostic criteria
The diagnosis of typical hyperthyroidism is not difficult. There is an uncontrolled history of hyperthyroidism. The symptoms and signs of hyperthyroidism, especially the presence of goiter with vascular murmurs and exophthalmos, are easy to diagnose. There are few typical manifestations in the elderly. The symptoms of a certain system are outstanding, and those over 70 years old should be alert to the indifferent type of hyperthyroidism crisis.
Differential diagnosis
The key to diagnosis is to determine the levels of serum TT4, TT3, FT4, FT3 and TSH (IRMA) as early as possible. Currently, these methods have been popularized, and special preparations such as iodine-free are not required. The measurement method is also more and more convenient, under emergency conditions. It is possible to confirm the diagnosis as early as possible.
The disease needs to be differentiated from certain common geriatric diseases:
1. High fever needs to be differentiated from serious infections (such as sepsis)
Hyperthyroidism is characterized by persistent high fever accompanied by sweating. The pulse rate is more obvious than the body temperature increase. The general cooling and anti-infective treatment is not effective, and other hyperthyroidism is more or less present.
2. Coronary heart disease arrhythmia, atrial fibrillation, atrial flutter, etc.
Hyperthyroidism in patients with general arrhythmia treatment is not effective, the use of beta blockers is better, there are other aspects of the presence of hyperthyroidism is an important basis for identification.
3. The hyperthyroidism with nausea, vomiting and diarrhea as a prominent manifestation may resemble acute gastroenteritis. The diarrhea of the hyperthyroid crisis may be increased, the stool or loose stool is dominant, the abdominal pain is not obvious, and the stool is not abnormal. May be accompanied by sweating, tachycardia and other symptoms of hyperthyroidism.
4. There is coma or restlessness with abnormal liver function and jaundice. The risk of hyperthyroidism should be differentiated from hepatic encephalopathy. It is difficult to distinguish the degree of liver damage and the interpretation of blood ammonia level and other signs of hyperthyroidism.
