Answer
a) Midline neck swelling
b) Thyroid storm
c) Management to this patient
- Triage the patient to red zone
- Oxygen with high flow mask 10-15L/min
- ECG to exlude spectrum of Acute coronary syndrome
- Monitor ECG, vital sign and pulse oxymetry every 10-15 minutes
- Establish peripheral line
- Fluid maintenance with dextrose-saline by slow infusion.
- Blood investigation (Thyroid function test, FBC, BUSE/Creatinine, LFT)
- CXR for evidence of heart failure and chest infection
- Urinalysis for evidence of UTI.
- Relieve the fever by paracetamol, tepid sponging or other cooling method. AVOID using ASPIRIN as it will release T4 and free T3 from it protein bound.
- Anti thyroid medication
i. Beta blocker (IV propanolol 1-2 mg slowly 4-6 hourly)
ii. Thyroid hormone formation inhibitor (propylthiouracil 600 mg stat or carbimazole 60-120 mg/day in 3 divided dose.
iii. Steroids for inhibit release of thyroid hormone and peripheral conversion T4 to T3 (IV dexamethasone 2mg 6 hourly)
- Treat underlying heart problem
- Refer the patient to endocrinologist or internal medical team.