Thyroid storm: Difference between revisions
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===Burch & Wartofsky Diagnostic Criteria=== | ===Burch & Wartofsky Diagnostic Criteria=== | ||
I. Thermoregulatory dysfunction (Temperature) | '''I. Thermoregulatory dysfunction (Temperature)''' | ||
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II. Central nervous system effects | '''II. Central nervous system effects''' | ||
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'''III. Gastrointestinal-hepatic dysfunction''' | |||
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'''IV. Cardiovascular dysfunction (tachycardia)''' | |||
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'''V. Congestive heart failure''' | |||
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'''VI. Precipitant history''' | |||
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Scoring | '''Scoring''' | ||
*>45 = Highly suggestive of thyroid storm | |||
>45 = Highly suggestive of thyroid storm | *25-44 = Suggestive of impending storm | ||
*<25 = Unlikely to represent storm | |||
25-44 = Suggestive of impending storm | |||
<25 = Unlikely to represent storm | |||
==<font size="100%">Treatment</font>== | ==<font size="100%">Treatment</font>== | ||
Revision as of 08:28, 12 March 2011
Background
Precipitating events:
- Infection
- Thyroid or nonthyroidal surgery
- Trauma
- Infection
- Acute iodine load
- Thyroiditis
Diagnosis
Classic 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
- PTU 600-1000 mg PO or PR followed by 200-250mg q4hr
- 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 250-500�/kg loading dose, then 50-100�g/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
- Fluid Resuscitation
�
See Also
Endo: Thyroid Data
Endo: Hyperthyroidism
Sources
Burch, HB, Wartofsky, L, Endocrinol Metab Clin North Am 1993; 22:263, UpToDate