Thyroid storm

Background

Precipitating events:

1. Infection
2. Thyroid or nonthyroidal surgery
3. Trauma
4. Infection
5. Acute iodine load
6. Thyroiditis

Diagnosis

Classic Triad

1. Hyperthermia
2. Tachycardia
3. AMS

Burch & Wartofsky Diagnostic Criteria

I. Thermoregulatory dysfunction (Temperature)

99-99.9	5
100-100.9	10
101-101.9	15
102-102.9	20
103-103.9	25
104.0	30

II. Central nervous system effects

Mild (Agitation)	10
Moderate (delirium, psychosis, extreme lethargy)	20
Severe (seizure, coma)	30

III. Gastrointestinal-hepatic dysfunction

Moderate (diarrhea, n/v,� abd pain)	10
Severe (unexplained jaundice)	20

IV. Cardiovascular dysfunction (tachycardia)

99-109	5
110-119	10
120-129	15
130-139	20
140	25

V. Congestive heart failure

Mild (pedal edema)	5
Moderate (bibasilar rales)	10
Severe (pulm edema, A. fib)	15

VI. Precipitant history

Negative	0
Positive	10

Scoring

>45 = Highly suggestive of thyroid storm

25-44 = Suggestive of impending storm

<25 = Unlikely to represent storm

Treatment

1. Block new hormone synthesis
   1. PTU 600-1000 mg PO or PR followed by 200-250mg q4hr
      1. Preferred to methimazole b/c also blocks T4>T3 conversion
   2. Methimazole 20-25mg q4hr
      1. Longer acting than PTU
2. Block hormone release
   1. Wolff-Chaikoff effect: increased iodine concentration leads to transient decrease of T3/T4
   2. Potassium iodide 5 gtt q6hr (Give 1hr after PTU)
      1. 1st line
   3. Lithium 300mg q6hr
      1. Consider if iodine allergic
3. Block Beta-adrenergic tone and peripheral T4>T3 conversion
   1. Propranolol PO 60-80 q4hr (if pt can tolerate PO)
   2. Propranolol IV 1mg over 10 min; if tolerates then 1-3mg boluses q3hr
   3. Esmolol 250-500�/kg loading dose, then 50-100�g/kg/min
4. Treat possible adrenal insufficiency (also blocks T4>T3)
   1. Hydrocortisone 100-300mg IV bolus, followed by 100mg q8hr�
5. Treat fever
   1. Active cooling measures
   2. Only consider acetaminophen if rule-out hepatic dysfunction
   3. Avoid aspirin (increases levels of free thryoid hormone)
6. Other Measures
   1. Fluid Resuscitation
      1. D5NS (most pts have depleted glycogen stores)
   2. Agitation control
      1. Benzos
   3. Thyroid hormone elimination
      1. Cholestyramine 4g q6hr
   4. Dialysis, plasmapharesis, or plasma exchange
      1. Consider if progressive deterioration despite multidrug tx

�

See Also

Endo: Thyroid Data

Endo: Hyperthyroidism

Sources

Burch, HB, Wartofsky, L, Endocrinol Metab Clin North Am 1993; 22:263, UpToDate

Thyroid Storm[/rename.php?renamepage=Thyroid%20Storm �]

Background

Precipitating events:

• Infection
• Thyroid or nonthyroidal surgery
• Trauma
• Infection
• Acute iodine load
• Thyroiditis

Diagnosis

• Triad: Hyperthermia, Tachycardia, AMS

Burch & Wartofsky Diagnostic Criteria I. Thermoregulatory dysfunction (Temperature)

99-99.9 5 100-100.9 10 101-101.9 15 102-102.9 20 103-103.9 25 104.0 30

II. Central nervous system effects

Mild (Agitation) 10 Moderate (delirium, psychosis, extreme lethargy) 20 Severe (seizure, coma) 30

III. Gastrointestinal-hepatic dysfunction Moderate (diarrhea, n/v, abd pain) 10 Severe (unexplained jaundice) 20

IV. Cardiovascular dysfunction (tachycardia) 99-109 5 110-119 10 120-129 15 130-139 20 140 25

V. Congestive heart failure Mild (pedal edema) 5 Moderate (bibasilar rales) 10 Severe (pulm edema, A. fib) 15

VI. Precipitant history Negative 0 Positive 10

Scoring

>45 = Highly suggestive of thyroid storm

25-44 = Suggestive of impending storm

<25 = Unlikely to represent storm

Treatment

• Block new hormone synthesis
• PTU 600-1000 mg PO or PR followed by 200-250mg q4hr
• Preferred to methimazole b/c also blocks T4>T3 conversion
• Methimazole 20-25mg q4hr
• Longer acting than PTU
• Block hormone release
• Wolff-Chaikoff effect: increased iodine concentration leads to transient decrease of T3/T4
• Potassium iodide 5 gtt q6hr (Give 1hr after PTU)
• 1st line
• Lithium 300mg q6hr
• Consider if iodine allergic
• Block Beta-adrenergic tone and peripheral T4>T3 conversion
• Propranolol PO 60-80 q4hr (if pt can tolerate PO)
• Propranolol IV 1mg over 10 min; if tolerates then 1-3mg boluses q3hr
• Esmolol 250-500µ/kg loading dose, then 50-100µg/kg/min
• Treat possible adrenal insufficiency (also blocks T4>T3)
• Hydrocortisone 100-300mg IV bolus, followed by 100mg q8hr
• Treat fever
• Active cooling measures
• Only consider acetaminophen if rule-out hepatic dysfunction
• Avoid aspirin (increases levels of free thryoid hormone)
• Other Measures
• Fluid Resuscitation
• D5NS (most pts have depleted glycogen stores)
• Agitation control
• Benzos
• Thyroid hormone elimination
• Cholestyramine 4g q6hr
• Dialysis, plasmapharesis, or plasma exchange
• Consider if progressive deterioration despite multidrug tx

==See Also==

Endo: Thyroid Data

Endo: Hyperthyroidism

Sources

Burch, HB, Wartofsky, L, Endocrinol Metab Clin North Am 1993; 22:263, UpToDate