Thyroid
Thyroid Storm
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Thyroid Storm
, Thyroid Crisis
See Also
Hyperthyroidism
Definitions
Thyroid Storm
Severe
Thyrotoxicosis
Causes
Uncontrolled
Hyperthyroidism
(esp.
Graves Disease
) with concurrent acute stress
Pulmonary Infection (most common cause)
Myocardial Ischemia
or
Myocardial Infarction
Cerebrovascular Accident
Trauma
or surgery
Gastrointestinal Illness
Pregnancy (including
Ectopic Pregnancy
)
Heat Illness
Hypothermia
Medications Affecting Thyroid Function
(includes
Drug-Induced Thyroiditis
)
Other, uncommon causes
Graves Disease
following
Radioactive Iodine
therapy
Pathophysiology
Up-regulation of
Beta Adrenergic Receptor
s are more responsive to circulating
Catecholamine
s (except in elderly)
Even a seemingly minor trigger, may precipitate the appearance of a hyperadrenergic state
Precautions
Elderly may present with minimal signs of
Thyrotoxicosis
(apathetic Thyroid Storm) with CHF, stupor to coma
Cell surface
Beta Adrenergic Receptor
s are present less in elderly and therefore decreased adrenergic response
Have a low threshold for
Thyroid
testing in the elderly
Young patients present more critically in Thyroid Storm
Increased sensitivity to circulating
Catecholamine
s results in severe, life-threatening presentations
Symptoms
See
Hyperthyroidism
Compared with typical
Hyperthyroidism
, Thyroid Storm presents more severe secondary symptoms
Fever
Altered Mental Status
(e.g.
Delirium
)
Dyspnea
(including
Orthopnea
)
Chest Pain
Signs
Fever
>39 C (102 F)
Hypertension
Sinus Tachycardia
or other tachydysrhythmia
Profuse sweating
High output cardiac failure (edema, pulmonary rales)
Tachyarrhythmias (esp.
Atrial Fibrillation
)
Altered Level of Consciousness
(
Delirium
,
Agitation
or
Psychosis
)
Differential Diagnosis
Sepsis
Sympathomimetic Toxicity
(
Stimulant Overdose
)
Alcohol Withdrawal
Malignant Hyperthermia
Neuroleptic Malignant Syndrome
Heat Related Illness
Associated Conditions
New onset
Atrial Fibrillation
New onset, unexplained
Congestive Heart Failure
Labs
Thyroid Stimulating Hormone
(TSH)
Suppressed in most cases
Increased in TRH-
Secretin
g Tumors (10-15% of Thyroid Storm cases)
Free T4
Increased
Broad based lab evaluation to cover differential diagnosis
Comprehensive Metabolic Panel
Liver Function Test
s,
Alkaline Phosphatase
and
Serum Calcium
may be increased
Complete Blood Count
Pregnancy Test
(bHCG) in women of child-bearing age
Imaging
Consider
Chest XRay
May demonstrate high output
Heart Failure
, precipitating events (e.g.
Pneumonia
)
Diagnostics
Electrocardiogram
Evaluate for
Arrhythmia
(e.g.
Atrial Fibrillation
,
PSVT
,
Sinus Tachycardia
)
Diagnosis
See
Thryoid Storm Diagnosis
(
Burch Wartofsky Score
)
Management
Gene
ral Measures
Manage Airway
Supplemental Oxygen
Intravenous Fluid
s
Dehydration
may occur due to gastrointestinal loss, increased basal metabolic rate
Cooling blanket and other external cooling
Avoid active cooling due to worsening the
Vasocon
striction already present with Thyroid Storm
Use
Acetaminophen
for fever
Avoid
Salicylate
s and
NSAID
S due to their increase of T4 and T3
NSAID
S and
Salicylate
s dislodge T4 from protein binding and allow for conversion to the more active T3
Treat concurrent infection (often inciting event)
Thyroid Storm alone (without infection) can also result in fever, and distinguishing the two may be difficult
Step 1:
Heart Rate
control (
Beta Blocker
s are preferred)
Beta Blocker
s (preferred)
Beta Blocker
s slow rate AND decrease peripheral conversion from T4 to the more active T3
Propranolol
10-20 mg IV every 4 hours (or 60 to 80 mg every 4 hours)
Most common
Beta Blocker
used in Thyroid Storm
Metoprolol
5-10 mg IV every 2-4 hours (or
Metoprolol Tartrate
50 mg every 6 hours)
Esmolol
50-100 mcg/kg/min IV
Diltiazem
(if
Beta Blocker
s are contraindicated)
Calcium Channel Blocker
s do not decrease peripheral conversion from T4 to the more active T3
Diltiazem
0.25 mg/kg IV bolus over 2 min, then 10 mg/h IV (or 60-90 mg orally every 6-8 hours)
Step 2: T4 and T3 Synthesis suppression with
Thionamide
s
Propylthiouracil
(PTU) 200-400 mg every 8 hours PO, PR, or per NG
Propylthiouracil
is preferred in first trimester of pregnancy
Most commonly used in Thyroid Storm, as it also decreases peripheral conversion of T4 to T3
Methimazole
20-40 mg every 8 hours IV, PO, PR, per NG
Methimazole
is preferred in second and third trimesters of pregnancy
Step 3: T4 and T3 Release suppression with
Iodine
Do NOT give before synthesis suppression (see step 2)
May otherwise promote new
Thyroid Hormone
synthesis
With all the focus on medication order in Thyroid Storm, this is the one critical step not to give too early
Must only be given at least 30-60 minutes AFTER
Thionamide
(PTU or
Methimazole
)
Iodine
has two mechisms of action
Increases
Thyroid Hormone
synthesis (worsening Thyroid Storm in absence of
Thionamide
)
Blocks release of stored
Thyroid Hormone
and decreases
Iodine
transport
Saturated Solution
Potassium
iodide (SSKI)
Dose: 5 drops mixed in fluid or food every 6 hours for at least 2 days
Initiate at least one hour after antithyroid medication
Step 4: T4 to T3 conversion suppression with
Glucocorticoid
s
Preparations
Hydrocortisone
100 mg IV every 8 hours OR
Dexamethasone
2 mg orally or IV every 6 hours OR
Betamethasone
0.5 mg orally, IV or IM every 6 hours
Additional benefits of
Corticosteroid
s (beyond T4 to T3 suppression)
Also counters autoimmune process in
Graves Disease
Manages concurrent
Adrenal Insufficiency
Step 5: Apheresis
Indicated in critically ill Thyroid Storm not responding to other measures
In theory, removes from the serum, excess
Thyroid Hormone
Complications
Atrial Fibrillation
Congestive Heart Failure
Critical to distinguish between high output
Heart Failure
and low output
Heart Failure
Often related to secondary
Atrial Fibrillation
with rapid ventricular rate (which improves with
Beta Blocker
s)
Bedside Ultrasound
Hyperdynamic heart activity is more consistent with high output
Heart Failure
Consider
Non-Invasive Positive Pressure Ventilation
(e.g. BIPAP)
Avoid
Diuretic
s (patients in Thyroid Storm are often hypovolemic)
References
Swaminathan and Willis in Herbert (2019) EM:Rap 19(10): 13-5
Swadron and Mason in Herbert (2019) EM:RAP C3 3(11): 1-10
Carroll (2010) Ther Adv Endocrinol Metab 1(3): 139–145 [PubMed]
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3475282/
Idrose (2015) Acute Med Surg 2(3): 147-57 +PMID: 29123713 [PubMed]
Kravets (2016) Am Fam Physician 93(5): 363-70 [PubMed]
Nayak (2006) Endocrinol Metab Clin North Am 35(4): 663-6 [PubMed]
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