A 28-year-old woman develops tachycardia in the postoperative recovery room. She was admitted for a right femur fracture following a motor vehicle collision and had an open reduction and internal fixation of the fracture. While in the recovery area, she began experiencing nausea and vomiting, and became anxious and agitated. The patient has no known medical problems. She drinks 1 or 2 glasses of wine on weekends. Her temperature is 39.4 C (103 F), blood pressure is 160/90 mm Hg, pulse is 148/min, and respirations are 24/min. Pulse oximetry shows 98% on room air. On examination, the patient is delirious and has fine tremor. Mild lid lag is present. She has no muscle rigidity and deep-tendon reflexes are 2+ in the bilateral extremities. Laboratory results are as follows: Which of the following is the best next step in management of this patient?

Question

A 28-year-old woman develops tachycardia in the postoperative recovery room.  She was admitted for a right femur fracture following a motor vehicle collision and had an open reduction and internal fixation of the fracture.  While in the recovery area, she began experiencing nausea and vomiting, and became anxious and agitated.  The patient has no known medical problems.  She drinks 1 or 2 glasses of wine on weekends.  Her temperature is 39.4 C (103 F), blood pressure is 160/90 mm Hg, pulse is 148/min, and respirations are 24/min.  Pulse oximetry shows 98% on room air.  On examination, the patient is delirious and has fine tremor.  Mild lid lag is present.  She has no muscle rigidity and deep-tendon reflexes are 2+ in the bilateral extremities.  Laboratory results are as follows:  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d8cb_e2bf_bc81_af610565cd3e_MD0003_00 This patient's presentation is concerning for thyroid storm, a life-threatening thyrotoxicosis usually triggered by a specific event (eg, thyroid or non-thyroid surgery, trauma, infection) in patients with undiagnosed or inadequately treated hyperthyroidism. Proposed mechanisms include a rapid increase in serum thyroid hormone levels or increased sensitivity to thyroid hormone. Characteristic features include tachycardia, hypertension, cardiac arrhythmias (eg, atrial fibrillation), and fever up to 40-41 C (104-106 F). Other findings include anxiety, altered mentation, seizure, severe nausea, vomiting, hepatic dysfunction, tremor, lid lag, and goiter. Diagnosis is suspected clinically and confirmed by thyroid function studies documenting hyperthyroidism. Treatment includes beta blockers (eg, propranolol) for symptom control, thionamides (eg, propylthiouracil) to block new hormone synthesis, iodine solution to block thyroid hormone release (given at least an hour after propylthiouracil to prevent excess iodine incorporation into thyroid hormone), and glucocorticoids to decrease peripheral conversion of T4 to T3 (and treat a potential relative adrenal insufficiency). (Choice A) Echocardiography can identify causes of congestive heart failure or arrhythmias (eg, abnormal valves, ventricular dysfunction). However, this patient has no features of heart failure, and echocardiography is not needed. (Choice B) Fluid resuscitation and intravenous dexamethasone should be given to patients with suspected acute adrenal insufficiency. These patients will have hypotension often associated with tachycardia, abdominal pain, vomiting, and weakness. acute adrenal insufficiency (Choice C) Intravenous dantrolene can treat malignant hyperthermia (MH), a hypermetabolic syndrome due to volatile anesthetics leading to sustained muscle contraction and breakdown. MH typically presents with hypercarbia, sinus tachycardia, muscle rigidity, significantly elevated creatine kinase (can reach >10,000-20,000 U/L), hyperkalemia (due to muscle breakdown), and hyperthermia. In this patient, the presence of lid lag, the absence of muscle rigidity, and the normokalemia are more consistent with thyroid storm than MH. Her moderate creatine kinase elevation likely reflects muscle injury related to trauma or surgery. (Choice D) Intravenous lorazepam can treat alcohol withdrawal, which usually presents with tachycardia, hypertension, and altered mental status. Fever is atypical with early withdrawal but can occur with delirium tremens, which develops 72-96 hours after the last drink. This patient's history of moderate alcohol use makes withdrawal less likely, and alcohol withdrawal would not explain her lid lag. (Choice E) Free plasma metanephrines are elevated in pheochromocytoma, which usually presents with episodic hypertension and the classic triad (episodic headache, diaphoresis, and tachycardia). Pheochromocytoma is usually not associated with high fever. Educational objective: Thyroid storm is a life-threatening thyrotoxicosis often triggered by thyroid or non-thyroid surgery, trauma, infection, iodine contrast, or childbirth. It is characterized by tachycardia, hypertension, cardiac arrhythmias, high fever, tremor, altered mentation, and lid lag. References: Thyroid storm: an updated review. (http://www.ncbi.nlm.nih.gov/pubmed/23920160)

A 28-Year-Old Woman Develops Tachycardia in the Postoperative Recovery Room