Thryoid storm question..........

[jorla9903]

i know that everyone dreads case studies but i am hoping that i can find some help. i have a case study that i am working on and i've been able to answer to every question, pretty well, but i have absolutely no idea on this question.

the overview is that the patient is going into thyroid storm.

here is the scenario

k.b is an 80 year old man admitted to the hospital following a 5 day "flu" with complaints of dyspnea, palpitations, chest pain, insomnia, and fatigue. his pmh includes hf, htn, requiring anti hypertensive meds that he states he has not been taking on reg. basis.

k.b was diagnosed with graves disease 6 months ago and placed on methimazole 15mg/day po. height 5 8 weight 130 appears anxious and restless, loud heart sounds, vs 150/90 104 ireg. 20, 100.2f 1+ pitting edema on lower extremities bilateral, diminished breath sounds with fine crackles. lab findings---- hgb 11.8 hct 36% esr 48 na 141 k+ 4.7 bun 33 creatinine 1.9 t4 14 t3 230.

after morning rounds, the physician leaves the following orders- propranolol inderal 20mg po q6h, dexamethasone decadron 10mg iv q6h, verapamil calan sr 120mg/day po, diet as tolerated, stat ecg, up ad lib.

the question that i can not figure out is:

which of these orders would you question and why?

i hope that someone will be able to help me because i have looked everywhere and i can not figure out why you would question any of these orders.......

[knittingmonster]

I would look up the drugs in my drug guide and look to see which one would be a problem with a thyroid storm. One of them is a problem.

[CBsMommy]

I would also look at the different drugs in the drug book. I can tell you without looking that propranolol, which is a nonselective B-Blocker, is not good for people who have diminished breath sounds (not to mention the numerous side effects with this drug)....BUT that may not be your answer so you need to look at the patient as a whole and really watch your drugs. Propranolol can also cause orthostatic hypotension and while your patient can get in and out of bed, I would teach them to do it REALLY slowly and with me present for a day or two (to watch their reaction to this drug). Good luck to you!

[jorla9903]

Thank you for the reply but believe me, I've been in 3 of my different drug books and maybe I'm just not seeing it but I do not see any reason. They all would be ordered with suspecting and trying to prevent thyroid storm.......

[knittingmonster]

I am using Davis's drug guide, 10th edition. When I look up propranolol, it states under contraindications/precautions to use cautiously in thyrotoxicosis because it may mask symptoms. I would think this would be the order to question.

[jorla9903]

Thank you. I have Pearson 2010 and 2009, both of them do have it under cautious use but just the word, it doesn't tell me why so I figured that it couldn't be that. Thank you that helps:)

[CBsMommy]

Ok. I looked this up because I need practice too!

verapamil is contraindicated for people with HF and seeing that your patient has a history of HF and already has edema (which can be a sign of heart failure) and high BP I would question this drug. Also, it states that concurrent use with a beta-blocker (propranolol) can cause HF. I think this is your answer.

I would still question propranolol as well for the reasons I listed above and also because the pt. needs to have continuous ECG monitoring (which was not mentioned above that the ECG was going to be continuous). I would probably suggest to the doctor using a selective beta blocker instead but the need would not be as immediate as not giving verapamil.

Hope this helps!

[elizabeth321]

There are a number of things I would question....based on experience and and research I have done since reading the question....

1. stat ecg and up at lib? If thyroid storm is suspected they should probably be on a monitor and on bed rest until stable

2. Decadron? The dose is too high. Everywhere I looked mention 2 mg every six hours

3. Propranolol is Beta-adrenergic blocking agents and a usual treatment for thyroid storm as it will treat the tachycardia and associated heart failure as will as it inhibits the conversion of T4 to T3. I am not sure why the Verapramil was ordered as well....the channel blocker is not the best choice for rate control in this situation I don't think and is contraindicated in CHF.Not sure if it is for BP? Not what I have seen typically.

That being said I would sure like it if you let us know what the answer is when you get it marked.

Great question.

[elizabeth321]

so what happened?

[Sendana]

Calcium-channel blockers reduce cardiac output my reducing myocardial contractility, right? I would question that order in a patient with heart failure.

What about diet as tolerated? Maybe he should be on fluid restriction.

[houstonjas]

I have actually been in thyroid storm, so I know that they do give inderal for sure to control the heart rate. The order I would have to question would be the diet as tolerated because it sounds as of the client is experiencing fluid volume excess AEB the edema, increased B/P and crackles in the lungs. That in combination with the fact that they have CHF would automatically have them on fluid restriction. Also you would want to keep them away from sodium and iodine found in seafood because I believe that iodine helps to convert T3 (I think). Also salt follows water. Hope this helps =)