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Updated: Dec 9 2021

Thyroid Storm

  • Snapshot
    • A 34-year-old female with a past medical history of well-controlled Graves disease is brought to the emergency room for altered mental status. She is post-operative day 4 from an laparoscopic appendectomy for acute appendicitis. Her temperature is 104.2°F (40.1°C), blood pressure is 160/110 mmHg, pulse is 145/min, respirations are 21/min, and oxygen saturation is 95% on room air.
  • Introduction
    • Clinical definition
      • life threatening condition characterized by symptoms of severe thyrotoxicosis (excessive thyroid hormone in the body)
      • often precipitated by an acute event/trigger
    • Associated conditions
      • hyperthyroidism
  • Epidemiology
    • Risk factors
      • longstanding, untreated hyperthyroidism
      • surgery
      • trauma
      • infection
      • parturition
      • irregular use or discontinuation of antithyroid drugs
  • Presentation
    • Symptoms
      • agitation
      • anxiety
      • delirium
      • coma
      • nausea/vomiting
      • diarrhea
      • abdominal pain
    • Physical exam
      • tachyarrythmia (can exceed 140 bpm)
      • hypotension/hypertension
      • hyperpyrexia
      • jaundice
  • Studies
    • Diagnostic testing
      • diagnostic approach
        • diagnosis is clinical and based the on presence of severe and life-threatening symptoms (e.g., hyperpyrexia, cardiovascular dysfunction, and altered mentation) in a patient with biochemical evidence of hyperthyroidism (e.g., elevated free T4/T3 and low TSH)
      • studies
        • thyroid function tests
          • usually not more profound than that seen in patients with uncomplicated thyrotoxicosis
          • low TSH
          • high free T4 and/or T3
        • liver function test
          • may see abnormal liver function tests
  • Differential
    • Sepsis
      • distinguishing factors
        • rarely the extreme tachycardia seen in thyroid storm
        • thyroid functioning tests will likely be normal in sepsis
  • Treatment
    • Management approach
      • management should be immediate following clinical diagnosis and patients should be managed at the intensive care unit (ICU) due to high mortality
    • First-line
      • β-blocker
        • control the symptoms and signs (e.g., tachycardia) induced by increased adrenergic tone
        • example
          • propranolol
      • thionamide
        • blocks new hormone synthesis
        • effective within 1-2 hours post administration
        • example
          • propylthiouracil (PTU) or methimazole
      • iodine solution
        • blocks release of thyroid hormone
          • known as the Wolff-Chaikoff effect
          • effective within 1-2 hours post administration
      • glucocorticoid
        • reduces T4 to T3 conversion
        • promotes vasomotor stability
        • reduce autoimmune process in Graves disease
        • treat associated relative adrenal insufficiency
    • Long-term management
      • in patients with Graves disease, definitive therapy with radioactive iodine or thyroidectomy may be indicated
  • Complications
    • Arrhythmias
    • Decompensated heart failure
    • Death
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