|About this Issue|
|Table of Contents|
The wide range and vague nature of clinical presentations of thyroid emergencies make accurate and timely diagnosis challenging. Patients with a variety of thyroid conditions present to the emergency department, and appropriate suspicion can reduce unnecessary delay and expense in determining the correct diagnosis. This issue reviews the current evidence for presentation, evaluation, and treatment for emergencies of thyroid function and anatomy including hypothyroidism, hyperthyroidism, thyroid nodules, and thyroid trauma. Complications of thyroid dysfunction are also considered, as well as recommendations for disposition and follow-up.
A 4-year-old boy presents to your ED, asymptomatic after suspected ingestion of 25 tablets of his grandmother’s 300-mcg levothyroxine. The ingestion occurred 90 minutes ago. You wonder: Is this amount toxic? Would serum hormone levels be helpful? What symptoms would be concerning? How should this patient be managed?
An 8-year-old boy with a history of Down syndrome is brought in by his parents because he is lethargic. He is difficult to rouse and has a history of vomiting and diarrhea for the last 4 days. His parents say this is very unusual for him, as he is usually constipated. The boy responds slowly to voice and shows signs of dehydration on examination. His mucous membranes are tacky, his capillary refill is 4 seconds, and he has cool extremities. The patient’s heart rate is 135 beats/min and his blood pressure is 100/60 mm Hg. A review of systems reveals no recent weight change, no unusual hair growth, and no temperature intolerance. In the waiting room, oral rehydration by syringe has been unsuccessful. While you suspect that dehydration is the cause of this patient's condition and begin to calculate fluid replacement, you recall that constipation can be a symptom of thyroid disease. Should you check the patient's thyroid stimulating hormone level while you start intravenous rehydration?
A 16-year-old adolescent girl is brought in by EMS for reported mania. According to her parents, she has been a good student, with no history of drug use. Her initial vital signs are: temperature, 38.9°C (102°F); heart rate, 120 beats/min; respiratory rate, 16 breaths/min; and blood pressure, 140/80 mm Hg. The patient is sweaty, pale, thrashing, and speaking rapidly and incomprehensibly. As you prepare to draw initial laboratory samples, you wonder if this could be a manifestation of hyperthyroidism, and whether drawing samples for thyroid stimulating hormone testing is appropriate. How will you manage this patient if there is evidence of thyrotoxicosis? Will it change your initial medications for treatment of the agitated patient? Are there important findings on other tests you need to watch for?
Thyroid disease is a common health problem in the population at large, but it does not often present to the emergency department (ED) as a primary concern. Thyroid disease is less common in children than adults. A Scottish population-based study found the prevalence of hypothyroidism to be 0.135% among all residents aged < 22 years. Of affected patients, 73% had acquired hypothyroidism, 66% of which had an autoimmune basis.1 In areas with screening programs, patients with congenital hypothyroidism are usually identified in the neonatal period; however, this condition may present later in infancy if screening was not performed or in children with diets low in iodine.
For an emergency clinician, thyroid disease is often difficult to diagnose, not only because it is uncommon, but because the signs and symptoms are vague and nonspecific and the variety of presentations is wide. This often leads to a delay in diagnosis. Two separate chart reviews2,3 demonstrated that children who were ultimately diagnosed with hyperthyroidism underwent testing for symptoms related to behavior (eg, attention deficit-hyperactivity disorder) or cardiac symptoms, were referred for non–endocrine subspecialist assessments 22.4% of the time, and underwent diagnostic testing and procedures costing as much as $14,000 per patient before their thyroid disease was confirmed.
Nonetheless, the ED provides an ideal setting to diagnose and arrange for treatment of thyroid disease. A fresh look at symptoms and signs, the availability of diagnostic testing, and access to pediatric subspecialists for follow-up makes thyroid disease relatively simple to diagnose and treat. Because of the severity of symptoms that can develop, the ED is also the site where acute thyrotoxicosis due to endogenous or exogenous hormone is most likely to present. This issue of Pediatric Emergency Medicine Practice reviews common presentations of various thyroid diseases and provides evidence-based recommendations for the management of patients with these diseases.
A literature search for articles published from 1990 to the present was performed in PubMed using the terms child, guidelines, thyroid emergencies, hypothyroid, hyperthyroid, thyroid trauma, and thyroid nodule. In addition, the Cochrane Database of Systematic Reviews was searched for reviews related to pediatric thyroid disease.
Recent high-level evidence for most thyroid disease is difficult to find. New evidence in the last 25 years is restricted to reviews, case reports, small studies, and clinical practice guidelines based on older evidence. Recent guidelines exist for the diagnosis and management of thyroid nodules,4,5 congenital hypothyroidism,6,7 childhood hypothyroidism,8,9 hyperthyroidism,10 and Graves disease.11
6. “My patient ingested a family member's thyroid medicine. I checked his thyroid levels when he came in, and they were normal. I don't understand how he got so much worse overnight.”
Young children are at risk for thyrotoxicosis from ingestion of levothyroxine, but usually do not show symptoms at the index visit. Ensure that repeat clinical assessments and laboratory evaluations are performed in follow-up.
7. “I gave acetaminophen to my patient with thyroid storm, but she just kept getting warmer and acting sicker!”
Propranolol and external cooling are the mainstays of ED treatment for thyroid storm. Antipyretics are of uncertain benefit, and salicylates in particular are contraindicated, as they may increase free thyroid hormone levels.
8. “Last week I saw a boy with recently diagnosed attention-deficit/hyperactivity disorder. He just had behavioral complaints, so I sent him home. He came back and was diagnosed with thyroid disease!”
Strongly consider evaluating TSH levels in patients with new behavioral complaints, unexplained cardiac complaints, or slipped capital femoral epiphysis.
Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of patients. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.
To help the reader judge the strength of each reference, pertinent information about the study is included in bold type following the reference, where available. In addition, the most informative references cited in this paper, as determined by the author, are highlighted.
Table 1. Manifestations of Hypothyroidism and Hyperthyroidism12,76
Clinical Pathway for the Management of Suspected Hypothyroidism
Clinical Pathway for the Management of Suspected Hyperthyroidism
Most Important References
Troy W. S. Turner, MD, FRCPC
Derya Caglar, MD, FAAP; Richard M. Cantor, MD, FAAP, FACEP
July 2, 2018
August 1, 2021
Physician CME Information
Date of Original Release: July 1, 2018. Date of most recent review: June 15, 2018. Termination date: July 1, 2021.
Accreditation: EB Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. This activity has been planned and implemented in accordance with the accreditation requirements and policies of the ACCME.
Credit Designation: EB Medicine designates this enduring material for a maximum of 4 AMA PRA Category 1 CreditsTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
ACEP Accreditation: Pediatric Emergency Medicine Practice is also approved by the American College of Emergency Physicians for 48 hours of ACEP Category I credit per annual subscription.
AAP Accreditation: This continuing medical education activity has been reviewed by the American Academy of Pediatrics and is acceptable for a maximum of 48 AAP credits per year. These credits can be applied toward the AAP CME/CPD Award available to Fellows and Candidate Fellows of the American Academy of Pediatrics.
AOA Accreditation: Pediatric Emergency Medicine Practice is eligible for up to 48 American Osteopathic Association Category 2-A or 2-B credit hours per year.
Needs Assessment: The need for this educational activity was determined by a survey of medical staff, including the editorial board of this publication; review of morbidity and mortality data from the CDC, AHA, NCHS, and ACEP; and evaluation of prior activities for emergency physicians.
Target Audience: This enduring material is designed for emergency medicine physicians, physician assistants, nurse practitioners, and residents.
Goals: Upon completion of this activity, you should be able to: (1) demonstrate medical decision-making based on the strongest clinical evidence; (2) cost-effectively diagnose and treat the most critical ED presentations; and (3) describe the most common medicolegal pitfalls for each topic covered.
Discussion of Investigational Information: As part of the journal, faculty may be presenting investigational information about pharmaceutical products that is outside Food and Drug Administration approved labeling. Information presented as part of this activity is intended solely as continuing medical education and is not intended to promote off-label use of any pharmaceutical product.
Faculty Disclosures: It is the policy of EB Medicine to ensure objectivity, balance, independence, transparency, and scientific rigor in all CME-sponsored educational activities. All faculty participating in the planning or implementation of a sponsored activity are expected to disclose to the audience any relevant financial relationships and to assist in resolving any conflict of interest that may arise from the relationship. Presenters must also make a meaningful disclosure to the audience of their discussions of unlabeled or unapproved drugs or devices. In compliance with all ACCME Essentials, Standards, and Guidelines, all faculty for this CME activity were asked to complete a full disclosure statement. The information received is as follows: Dr. Turner, Dr. Caglar, Dr. Cantor, Dr. Claudius, Dr. Horeczko, Dr. Mishler, and their related parties report no significant financial interest or other relationship with the manufacturer(s) of any commercial product(s) discussed in this educational presentation. Dr. Jagoda made the following disclosures: Consultant, Daiichi Sankyo Inc; Consultant, Pfizer Inc; Consultant, Banyan Biomarkers Inc; Consulting fees, EB Medicine.
Commercial Support: This issue of Pediatric Emergency Medicine Practice did not receive any commercial support.
Earning Credit: Two Convenient Methods: (1) Go online to www.ebmedicine.net/CME and click on the title of this article. (2) Mail or fax the CME Answer And Evaluation Form with your June and December issues to Pediatric Emergency Medicine Practice.
Hardware/Software Requirements: You will need a Macintosh or PC with internet capabilities to access the website.
Additional Policies: For additional policies, including our statement of conflict of interest, source of funding, statement of informed consent, and statement of human and animal rights, visit https://www.ebmedicine.net/policies.