Thyroid storm: Difference between revisions

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*Mortality  
*Mortality  
**Without treatment: 80-100%  
**Without treatment: 80-100%  
**With treatment: 15-50%
**With treatment: 10-30%<ref>Thiessen, M. (2018). Thyroid and Adrenal Disorders in Rosen's emergency medicine: Concepts and clinical practice (9th ed.). Philadelphia, PA: Elsevier/Saunders.</ref>
*Difference between severe thyrotoxicosis and thyroid storm is clinical diagnosis<ref>Nayak B1, Burman K. Thyrotoxicosis and thyroid storm. Endocrinol Metab Clin North Am. 2006 Dec;35(4):663-86, vii.</ref>
*Difference between severe thyrotoxicosis and thyroid storm is clinical diagnosis<ref>Nayak B1, Burman K. Thyrotoxicosis and thyroid storm. Endocrinol Metab Clin North Am. 2006 Dec;35(4):663-86, vii.</ref>
**Must empirically treat before TFTs back from lab
**Must empirically treat before laboratory confirmation
**Thyroid storm will present with classic triad and history of hyperthyroid with precipitant
**Death caused by multi-organ dysfunction, congestive heart failure, respiratory failure, disrhythmias, [[DIC]], hypoxic brain injury, or sepsis <ref>Thiessen, M. (2018). Thyroid and Adrenal Disorders in Rosen's emergency medicine: Concepts and clinical practice (9th ed.). Philadelphia, PA: Elsevier/Saunders.</ref>


===Precipitants===
===Precipitants===
*Infection  
*Long-standing untreated [[hyperthyroidism]]
*Trauma
*[[Infection]]
*[[Trauma]]
*Recent thyroid manipulation (physical or surgical)
*Recent thyroid manipulation (physical or surgical)
*[[Burns]]
*[[Burns]]
*Surgery  
*Surgery (non-thyroid)
*[[DKA]]  
*[[DKA]]  
*Withdrawal of thyroid medication  
*Withdrawal of thyroid medication  
*Iodine administration
*[[Lithium]] withdrawal
*Iodine load (contrast media or [[amiodarone]]<ref>Thiessen, M. (2018). Thyroid and Adrenal Disorders in Rosen's emergency medicine: Concepts and clinical practice (9th ed.). Philadelphia, PA: Elsevier/Saunders.</ref>)
*[[MI]]  
*[[MI]]  
*[[CVA]]  
*[[CVA]]  
*[[PE]]
*[[PE]]
*Interferon treatment
*[[Interferon-α]] treatment
*Molar Pregnancy
*Recent [[delivery|parturition]]
*[[Molar pregnancy]]
*[[Hypoglycemia]]
*[[Hypoglycemia]]
*Withdrawl of antithyroid treatment
*[[Hyperemesis gravidarum]] <ref>Thiessen, M. (2018). Thyroid and Adrenal Disorders in Rosen's emergency medicine: Concepts and clinical practice (9th ed.). Philadelphia, PA: Elsevier/Saunders.</ref>
*Exposure to iodine (or iodinated contrast)
*Toxemia of pregnancy <ref>Thiessen, M. (2018). Thyroid and Adrenal Disorders in Rosen's emergency medicine: Concepts and clinical practice (9th ed.). Philadelphia, PA: Elsevier/Saunders.</ref>
 
{{Thyroid gen background}}


==Clinical Features==
==Clinical Features==
[[File:PMC5384127 TJO-47-94-g6.png|thumb|Bilateral infiltrative thyroid-associated exophthalmos]]
[[File:PMC3742527 OL-06-01-0144-g00.png|thumb|Enlarged and homogeneous thyroid.]]
[[File:PMC3371544 IJD-57-247-g002.png|thumb|"Plummer's nail" demonstrating onycholysis (separation of the nail from the nail bed). Abnormal nail findings occurs in about 5% of hyperthyroid patients.]]
===Classic Triad===
===Classic Triad===
*[[Hyperthermia]]  
*[[Hyperthermia]]
*Tachycardia  
**Often marked (40 - 41C)<ref>Thiessen, M. (2018). Thyroid and Adrenal Disorders in Rosen's emergency medicine: Concepts and clinical practice (9th ed.). Philadelphia, PA: Elsevier/Saunders.</ref>
*[[altered mental status]] (agitation, confusion, [[delirium]] stupor, [[coma]], [[seizure]])
*[[Tachycardia]]
**Often out of proportion to fever <ref>Thiessen, M. (2018). Thyroid and Adrenal Disorders in Rosen's emergency medicine: Concepts and clinical practice (9th ed.). Philadelphia, PA: Elsevier/Saunders.</ref>
*[[Altered mental status]] (agitation, confusion, [[delirium]] stupor, [[coma]], [[seizure]])
*May also have:  
*May also have:  
**[[CHF]]
**[[CHF]]
Line 38: Line 48:
**Hyperhidrosis
**Hyperhidrosis
**Thyrotoxic stare, lid retraction
**Thyrotoxic stare, lid retraction
**Goitre
**[[Tremor]]
===Complications===
*Cardiovascular collapse<ref>Thiessen, M. (2018). Thyroid and Adrenal Disorders in Rosen's emergency medicine: Concepts and clinical practice (9th ed.). Philadelphia, PA: Elsevier/Saunders.</ref>
**[[Congestive heart failure]]
**[[Hypotension]]
**Cardiac [[dysrhythmias]]
*[[Hypovolemia]], [[hypotension]]
**Due to nausea, [[vomiting]], [[diarrhea]]
*[[Hepatic failure]] with cholestatic jaundice <ref>Thiessen, M. (2018). Thyroid and Adrenal Disorders in Rosen's emergency medicine: Concepts and clinical practice (9th ed.). Philadelphia, PA: Elsevier/Saunders.</ref>
**Rare but carries poor prognosis
===Apathetic Hyperthyroidism===
===Apathetic Hyperthyroidism===
*Strikingly different rare form, dominated by depressed mental status, cardiac complications<ref>Parker KI et al. A case of apathetic thyroid storm with resultant hyperthyroidism-induced hypercalcemia. Am J Med Sci. 2013 Oct;346(4):338-40.</ref>
*Strikingly different rare form, dominated by depressed mental status, cardiac complications<ref>Parker KI et al. A case of apathetic thyroid storm with resultant hyperthyroidism-induced hypercalcemia. Am J Med Sci. 2013 Oct;346(4):338-40.</ref>
*Treatment with antithyroid therapy is still mainstay
*Treatment with antithyroid therapy is still mainstay
*More common in elderly patients <ref>Poudel RR et al. Apathetic thyrotoxicosis presenting with diabetes mellitus. J Community Hosp Intern Med Perspect. 2014 4(5).</ref>


==Differential Diagnosis==
==Differential Diagnosis==
{{altered mental status and fever DDX}}
{{Widened Pulse Pressure DDX}}
{{Widened Pulse Pressure DDX}}


==Evaluation==
==Evaluation==
===Work-Up===
===Workup===
*Chemistry (creatinine may be low or High Ca)
*TSH
*CBC (may have [[Thrombocytopenia]])
**Low or undetectable
*LFTs (using PTU vs. methimazole, see below)
*Free T3/T4
*TSH/Free T3/T4
**Elevated
*Chemistry
**[[hypercalcemia|Calcium]] may be elevated
**[[Hyperglycemia]] often present <ref>Thiessen, M. (2018). Thyroid and Adrenal Disorders in Rosen's emergency medicine: Concepts and clinical practice (9th ed.). Philadelphia, PA: Elsevier/Saunders.</ref>
*CBC
**May have [[thrombocytopenia]]
**[[Leukocytosis]] common <ref>Thiessen, M. (2018). Thyroid and Adrenal Disorders in Rosen's emergency medicine: Concepts and clinical practice (9th ed.). Philadelphia, PA: Elsevier/Saunders.</ref>
*[[LFTs]]
**Mild elevation in AST, ALT, LDH, bilirubin, ALP may be seen <ref>Thiessen, M. (2018). Thyroid and Adrenal Disorders in Rosen's emergency medicine: Concepts and clinical practice (9th ed.). Philadelphia, PA: Elsevier/Saunders.</ref>
*Cortisol level (rule-out concurrent adrenal insufficiency)  
*Cortisol level (rule-out concurrent adrenal insufficiency)  
*[[ECG]]  
*[[ECG]]  
*Rule-out infection:  
*Rule out infection:  
**[[CXR]]
**[[CXR]]
**[[Blood culture]]
**[[Blood culture]]
**[[UA]]
**Consider [[lumbar puncture]] after CTH
===Diagnosis===
[[File:thyroid studies.JPG|px200]]


===Burch & Wartofsky Diagnostic Criteria===
===Burch & Wartofsky Diagnostic Criteria===
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#'''[[Dehydration]]/[[hypoglycemia]]'''
#'''[[Dehydration]]/[[hypoglycemia]]'''
#*D5NS (most patients have depleted glycogen stores)  
#*D5NS (most patients have depleted glycogen stores)  
#*Crackles in lungs are likely high output HF, NOT fluid overload
#*Crackles in lungs are likely [[high output heart failure]], NOT fluid overload
#Cardiac decompensation ([[CHF]], [[A-fib]])  
#Cardiac decompensation ([[CHF]], [[A-fib]])  
#*Rate control, inotropes, diuretics as needed (short acting always better)
#*Rate control, inotropes, diuretics as needed (short acting always better)
#Agitation
#Agitation
#*Benzodiazepines are the preferred agent
#*[[Benzodiazepines]] are the preferred agent


===Treat Increased Adrenergic Tone===
===Treat Increased Adrenergic Tone===
*[[Propranolol]] PO 60-80 q4hr (if patient can tolerate PO)
*[[Propranolol]] PO 60-80 mg q4hr (if can tolerate PO, no PR form)
:''or''
:''or''
*[[Propranolol]] IV 1-2mg over 10 min; if tolerates then 1-2mg boluses q15 minutes until HR <100<ref>http://emcrit.org/podcasts/thyroid-storm/ EMCrit - Thryoid Storm (149)</ref>
*[[Propranolol]] IV 1-2mg over 10 min; if tolerates then 1-2mg boluses q15 minutes until HR <100<ref>http://emcrit.org/podcasts/thyroid-storm/ EMCrit - Thryoid Storm (149)</ref>
Line 158: Line 194:
**Relative contraindications are same as for other medical conditions (e.g. [[CHF]], [[Reactive Airway Disease]], see alternative therapies)
**Relative contraindications are same as for other medical conditions (e.g. [[CHF]], [[Reactive Airway Disease]], see alternative therapies)
**In addition to decreasing peripheral conversion, propranolol will improve tremor, hyperpyrexia, and agitation
**In addition to decreasing peripheral conversion, propranolol will improve tremor, hyperpyrexia, and agitation
**Unlike other beta-blockers, propranolol also partially blocks conversion of T3 to T4
:''or''
:''or''
*[[Esmolol]] 250-500mcg/kg loading dose, then 50-100mcg/kg/min<ref>Brunette DD, Rothong C. Emergency department management of thyrotoxic crisis with esmolol. Am J Emerg Med. 1991;9(3):232-4.</ref>
*[[Esmolol]] 250-500mcg/kg loading dose, then 50-100mcg/kg/min<ref>Brunette DD, Rothong C. Emergency department management of thyrotoxic crisis with esmolol. Am J Emerg Med. 1991;9(3):232-4.</ref>
**B1 selective so can be used with active CHF, asthma, etc; but does not perform other benefits of propranolol
**B1 selective so can be used with active CHF, asthma, etc
**Does not have T3 to T4 blocking properties of propranolol
:''or''
*Reserpine 2.5 - 5 mg IM q4h
**Option for patients in whom beta-blockers are contraindicated <ref>Thiessen, M. (2018). Thyroid and Adrenal Disorders in Rosen's Emergency Medicine (9th ed.). Philadelphia, PA: Elsevier/Saunders.</ref>


===Block New Hormone Synthesis<ref>Doses based on American Association of Clinical Endocrinologists recommendations</ref>===
===Block New Hormone Synthesis<ref>Doses based on American Association of Clinical Endocrinologists recommendations</ref>===
''Thionamides are the main class of medications which prevent new hormone synthesis by inhibiting the iodination of tyrosine residues by thyroid peroxidase (TPO) enzymes. Propylthiouracil (PTU) is prefered over methimazole because it will also bock T4->T3 conversion''
''Thionamides are the main class of medications which prevent new hormone synthesis by inhibiting the iodination of tyrosine residues by thyroid peroxidase (TPO) enzymes. Propylthiouracil (PTU) is prefered over methimazole because it will also bock T4→T3 conversion''
#'''PTU''' 600-1000mg PO or PR followed by 200-250mg q4hr  
#'''[[PTU]]''' 500-1000mg PO or NG followed by 250mg q4hr  
#*May provide PR, but PO or NG are preferred routes (IV formulations not available in US)
#*Note black box warning of hepatotoxicity so check LFTs prior
#*Note black box warning of hepatotoxicity so check LFTs prior
#*Avoid in patients with significant liver disease; use methimazole instead
#*Avoid in patients with significant liver disease; use methimazole instead
#'''Methimazole''' 20-25mg q4hr  
#*Theoretically first line and offers advantage over methimazole
#**PTU has earlier onset of action and capacity to inhibit peripheral conversion of T4 to T3
#**However, no significant difference in mortality between PTU and methimazole<ref>Isozaki O et al. Treatment and management of thyroid storm: analysis of the nationwide surveys: The taskforce committee of the Japan Thyroid Association and Japan Endocrine Society for the establishment of diagnostic criteria and nationwide surveys for thyroid storm. Clin Endocrinol (Oxf).  2016; 84(6):912-8 (ISSN: 1365-2265).</ref>
#'''[[Methimazole]]''' 20-25mg q4hr (80 - 100 mg daily in divided doses)
#*Longer acting than PTU
#*Longer acting than PTU
#*IV formulations may be available in Europe
#*Should be avoided in pregnancy by classic teaching (freely crosses placenta, birth defects)
#*Should be avoided in pregnancy by classic teaching (freely crosses placenta, birth defects)
#'''Potassium iodide (SSKI)'''
#*Available in IV formulations outside America, but use supported by case reports only <ref>Thiessen, M. (2018). Thyroid and Adrenal Disorders. Rosen's Emergency Medicine (9th ed). Philadelphia, PA: Elsevier/Saunders.</ref>
#*Give 1hr after PTU to prevent increased hormone production (Jod-Basedow effect)<ref name="chiha">Chiha M. et al Thyroid storm: an updated review. J Intensive Care Med. 2015 Mar;30(3):131-40. </ref>
#'''[[Potassium iodide]] (SSKI)'''
#*Give 1hr after PTU or methimazole to prevent increased hormone production (Jod-Basedow effect)<ref name="chiha">Chiha M. et al Thyroid storm: an updated review. J Intensive Care Med. 2015 Mar;30(3):131-40. </ref>
#*Block hormone release: (Wolff-Chaikoff effect) only after hormone synthesis is inhibited. Iodine concentration leads to transient decrease of T3/T4  
#*Block hormone release: (Wolff-Chaikoff effect) only after hormone synthesis is inhibited. Iodine concentration leads to transient decrease of T3/T4  
#*5 drops (0.25 mL or 250mg) orally every 6 hours
#*5 drops (0.25 mL or 250mg) orally every 6 hours
#*Avoid potassium iodide if patient is on amiodarone
#*Avoid potassium iodide if patient is on amiodarone
#*Can substitute radiocontrast dyes (Iopanoic acid, ipodate and iopanoate), PO Lugol solution, OR IV sodium iodide <ref>Weingart, Scott. EMCRIT Thyroid Storm Show Notes. http://emcrit.org/podcasts/thyroid-storm/ </ref>
#*Can substitute radiocontrast dyes (Iopanoic acid, ipodate and iopanoate), PO Lugol solution, '''OR''' IV sodium iodide <ref>Weingart, Scott. EMCRIT Thyroid Storm Show Notes. http://emcrit.org/podcasts/thyroid-storm/ </ref>
#Lithium carbonate<ref>Carroll R, Matfin G. Endocrine and metabolic emergencies: thyroid storm. Ther Adv Endocrinol Metab. 2010 Jun; 1(3): 139–145. [http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3475282/ Full Text]</ref>
#[[Lithium]] carbonate<ref>Carroll R, Matfin G. Endocrine and metabolic emergencies: thyroid storm. Ther Adv Endocrinol Metab. 2010 Jun; 1(3): 139–145. [http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3475282/ Full Text]</ref>
#*Consider if iodine allergic
#*Consider if iodine allergic
#*'''Lithium carbonate''' 300mg PO q8hr
#*'''Lithium carbonate''' 300mg PO q8hr
#*Lithium inhibits thyroid hormone release from the gland and reduces iodination of tyrosine residues, but its use is complicated by the toxicity that can ensue.
#*Lithium inhibits thyroid hormone release from the gland and reduces iodination of tyrosine residues, but its use is complicated by the toxicity that can ensue
#*Treatment of choice for iodine-induced hyperthyroidism as the result of contrast load or amiodarone
#Lugol’s Solution 8 drops PO q 6 ''(alternative iodine source)''
#Lugol’s Solution 8 drops PO q 6 ''(alternative iodine source)''
#Sodium Iodide 0.5mg IV Q 12 hours ''(alternative iodine source)''
#Sodium Iodide 0.5mg IV Q 12 hours ''(alternative iodine source)''
Line 185: Line 233:
===Adrenal Insufficiency Treatment===
===Adrenal Insufficiency Treatment===
''Often there may be associated [[adrenal insufficiency]] (also blocks T4>T3)''
''Often there may be associated [[adrenal insufficiency]] (also blocks T4>T3)''
*[[Hydrocortisone]] 100-300mg IV bolus, followed by 100mg q8hr OR
*[[Hydrocortisone]] 300mg IV bolus, followed by 100mg TID for several days '''OR'''
*[[Dexamethasone]] 4mg IV q6hr
*[[Dexamethasone]] 4mg IV q6hr
*Note that corticosteroids also inhibit conversion of T4 to T3 and block release of hormone from thyroid gland


===Plasmapheresis<ref>Muller C et al. Role of plasma exchange in the thyroid storm. Ther Apher Dial. 2011 Dec;15(6):522-31.</ref>===
===[[Plasmapheresis]]<ref>Muller C et al. Role of plasma exchange in the thyroid storm. Ther Apher Dial. 2011 Dec;15(6):522-31.</ref>===
*For recalcitrant thyroid storm, with remaining cardiac and neurologic symptoms
*For recalcitrant thyroid storm, with remaining cardiac and neurologic symptoms
*Especially in the case of fulminant liver failure, in which anti-thyroid drugs are contraindicated<ref>Garg N et al. CALMING THE STORM - ROLE OF PLASMAPHERESIS IN THYROTOXIC CRISES. The Endocrine Society's 95th Annual Meeting and Expo, June 15–18, 2013 - San Francisco.</ref>
*Especially in the case of fulminant liver failure, in which anti-thyroid drugs are contraindicated<ref>Garg N et al. CALMING THE ST'''OR'''M - ROLE OF PLASMAPHERESIS IN THYROTOXIC CRISES. The Endocrine Society's 95th Annual Meeting and Expo, June 15–18, 2013 - San Francisco.</ref>
*Repeat sessions until TFTs normalize
*Repeat sessions until TFTs normalize
*Removes cytokines, auto-antibodies, thyroid hormones, thyroid hormone bound proteins
*Removes cytokines, auto-antibodies, thyroid hormones, thyroid hormone bound proteins
===Antibiotics===
*Second most common etiology of thyroid storm (after medication noncompliance) is infection <ref>Akamizu T, et al. Diagnostic criteria, clinical features, and incidence of thyroid storm based on nationwide surveys. Thyroid 2012; 22:661. </ref>
*Low threshold to start broad spectrum antibiotics


==Disposition==
==Disposition==
Line 201: Line 254:


==External Links==
==External Links==
*[https://www.youtube.com/watch?v=LWOByFjjemc Thyroid Storm YouTube Video]
*[http://emcrit.org/podcasts/thyroid-storm/ EMCrit - Thryoid Storm (149)]
*[http://emcrit.org/podcasts/thyroid-storm/ EMCrit - Thryoid Storm (149)]
==Video==
{{#widget:YouTube|id=LWOByFjjemc}}


==References==
==References==

Revision as of 23:24, 17 December 2019

Background

  • Mortality
    • Without treatment: 80-100%
    • With treatment: 10-30%[1]
  • Difference between severe thyrotoxicosis and thyroid storm is clinical diagnosis[2]
    • Must empirically treat before laboratory confirmation
    • Death caused by multi-organ dysfunction, congestive heart failure, respiratory failure, disrhythmias, DIC, hypoxic brain injury, or sepsis [3]

Precipitants

Spectrum of Thyroid Disease

Thyroid physiology

Clinical Features

Bilateral infiltrative thyroid-associated exophthalmos
Enlarged and homogeneous thyroid.
"Plummer's nail" demonstrating onycholysis (separation of the nail from the nail bed). Abnormal nail findings occurs in about 5% of hyperthyroid patients.

Classic Triad

Complications

Apathetic Hyperthyroidism

  • Strikingly different rare form, dominated by depressed mental status, cardiac complications[11]
  • Treatment with antithyroid therapy is still mainstay
  • More common in elderly patients [12]

Differential Diagnosis

Evaluation

Workup

Diagnosis

px200

Burch & Wartofsky Diagnostic Criteria

Category Points
Thermoregulatory dysfunction (°F)
Tmax= 99-99.9 5
Tmax= 100-100.9 10
Tmax= 101-101.9 15
Tmax= 102-102.9 20
Tmax= 103-103.9 25
Tmax= 104 30
Central nervous system effects
Mild (Agitation) 10
Moderate (delirium, psychosis, extreme lethargy) 20
Severe (seizure, coma) 30
Gastrointestinal-hepatic dysfunction
Moderate (diarrhea, nausea and vomiting, abdominal pain) 10
Severe (unexplained jaundice) 20
Cardiovascular dysfunction (tachycardia)
HR= 99-109 5
HR= 110-119 10
HR= 120-129 15
HR= 130-139 20
HR= 140 25
Congestive Heart Failure
Mild (pedal edema) 5
Moderate (bibasilar rales) 10
Severe (pulmonary edema, A. fib) 15
Precipitant history
Negative 0
Positive 10

Scoring[16]

  • >45 = Highly suggestive of thyroid storm
  • 25-44 = Suggestive of impending storm
  • <25 = Unlikely to represent storm

Management[17]

Identify precipitant (i.e. med noncompliance, DKA, infection). When in doubt of diagnosis, the EP should treat given the high mortality rate, as a few doses of anti-thyroid medication are unlikely to harm euthyroid patient[18]

Supportive care

  1. Fever
    • Do not aggressively cool as this can lead to vasoconstriction[19]
    • Careful cooling measures (ice packs & cooling blankets)
    • Acetaminophen (avoid aspirin or NSAIDS because they displace thyroid hormone from TBG)
  2. Dehydration/hypoglycemia
    • D5NS (most patients have depleted glycogen stores)
    • Crackles in lungs are likely high output heart failure, NOT fluid overload
  3. Cardiac decompensation (CHF, A-fib)
    • Rate control, inotropes, diuretics as needed (short acting always better)
  4. Agitation

Treat Increased Adrenergic Tone

  • Propranolol PO 60-80 mg q4hr (if can tolerate PO, no PR form)
or
  • Propranolol IV 1-2mg over 10 min; if tolerates then 1-2mg boluses q15 minutes until HR <100[20]
    • Followed by drip at dose required for heart rate control (3-5mg/hr)
    • Relative contraindications are same as for other medical conditions (e.g. CHF, Reactive Airway Disease, see alternative therapies)
    • In addition to decreasing peripheral conversion, propranolol will improve tremor, hyperpyrexia, and agitation
    • Unlike other beta-blockers, propranolol also partially blocks conversion of T3 to T4
or
  • Esmolol 250-500mcg/kg loading dose, then 50-100mcg/kg/min[21]
    • B1 selective so can be used with active CHF, asthma, etc
    • Does not have T3 to T4 blocking properties of propranolol
or
  • Reserpine 2.5 - 5 mg IM q4h
    • Option for patients in whom beta-blockers are contraindicated [22]

Block New Hormone Synthesis[23]

Thionamides are the main class of medications which prevent new hormone synthesis by inhibiting the iodination of tyrosine residues by thyroid peroxidase (TPO) enzymes. Propylthiouracil (PTU) is prefered over methimazole because it will also bock T4→T3 conversion

  1. PTU 500-1000mg PO or NG followed by 250mg q4hr
    • May provide PR, but PO or NG are preferred routes (IV formulations not available in US)
    • Note black box warning of hepatotoxicity so check LFTs prior
    • Avoid in patients with significant liver disease; use methimazole instead
    • Theoretically first line and offers advantage over methimazole
      • PTU has earlier onset of action and capacity to inhibit peripheral conversion of T4 to T3
      • However, no significant difference in mortality between PTU and methimazole[24]
  2. Methimazole 20-25mg q4hr (80 - 100 mg daily in divided doses)
    • Longer acting than PTU
    • IV formulations may be available in Europe
    • Should be avoided in pregnancy by classic teaching (freely crosses placenta, birth defects)
    • Available in IV formulations outside America, but use supported by case reports only [25]
  3. Potassium iodide (SSKI)
    • Give 1hr after PTU or methimazole to prevent increased hormone production (Jod-Basedow effect)[26]
    • Block hormone release: (Wolff-Chaikoff effect) only after hormone synthesis is inhibited. Iodine concentration leads to transient decrease of T3/T4
    • 5 drops (0.25 mL or 250mg) orally every 6 hours
    • Avoid potassium iodide if patient is on amiodarone
    • Can substitute radiocontrast dyes (Iopanoic acid, ipodate and iopanoate), PO Lugol solution, OR IV sodium iodide [27]
  4. Lithium carbonate[28]
    • Consider if iodine allergic
    • Lithium carbonate 300mg PO q8hr
    • Lithium inhibits thyroid hormone release from the gland and reduces iodination of tyrosine residues, but its use is complicated by the toxicity that can ensue
    • Treatment of choice for iodine-induced hyperthyroidism as the result of contrast load or amiodarone
  5. Lugol’s Solution 8 drops PO q 6 (alternative iodine source)
  6. Sodium Iodide 0.5mg IV Q 12 hours (alternative iodine source)

Adrenal Insufficiency Treatment

Often there may be associated adrenal insufficiency (also blocks T4>T3)

  • Hydrocortisone 300mg IV bolus, followed by 100mg TID for several days OR
  • Dexamethasone 4mg IV q6hr
  • Note that corticosteroids also inhibit conversion of T4 to T3 and block release of hormone from thyroid gland

Plasmapheresis[29]

  • For recalcitrant thyroid storm, with remaining cardiac and neurologic symptoms
  • Especially in the case of fulminant liver failure, in which anti-thyroid drugs are contraindicated[30]
  • Repeat sessions until TFTs normalize
  • Removes cytokines, auto-antibodies, thyroid hormones, thyroid hormone bound proteins

Antibiotics

  • Second most common etiology of thyroid storm (after medication noncompliance) is infection [31]
  • Low threshold to start broad spectrum antibiotics

Disposition

  • Admission to ICU

See Also

External Links

References

  1. Thiessen, M. (2018). Thyroid and Adrenal Disorders in Rosen's emergency medicine: Concepts and clinical practice (9th ed.). Philadelphia, PA: Elsevier/Saunders.
  2. Nayak B1, Burman K. Thyrotoxicosis and thyroid storm. Endocrinol Metab Clin North Am. 2006 Dec;35(4):663-86, vii.
  3. Thiessen, M. (2018). Thyroid and Adrenal Disorders in Rosen's emergency medicine: Concepts and clinical practice (9th ed.). Philadelphia, PA: Elsevier/Saunders.
  4. Thiessen, M. (2018). Thyroid and Adrenal Disorders in Rosen's emergency medicine: Concepts and clinical practice (9th ed.). Philadelphia, PA: Elsevier/Saunders.
  5. Thiessen, M. (2018). Thyroid and Adrenal Disorders in Rosen's emergency medicine: Concepts and clinical practice (9th ed.). Philadelphia, PA: Elsevier/Saunders.
  6. Thiessen, M. (2018). Thyroid and Adrenal Disorders in Rosen's emergency medicine: Concepts and clinical practice (9th ed.). Philadelphia, PA: Elsevier/Saunders.
  7. Thiessen, M. (2018). Thyroid and Adrenal Disorders in Rosen's emergency medicine: Concepts and clinical practice (9th ed.). Philadelphia, PA: Elsevier/Saunders.
  8. Thiessen, M. (2018). Thyroid and Adrenal Disorders in Rosen's emergency medicine: Concepts and clinical practice (9th ed.). Philadelphia, PA: Elsevier/Saunders.
  9. Thiessen, M. (2018). Thyroid and Adrenal Disorders in Rosen's emergency medicine: Concepts and clinical practice (9th ed.). Philadelphia, PA: Elsevier/Saunders.
  10. Thiessen, M. (2018). Thyroid and Adrenal Disorders in Rosen's emergency medicine: Concepts and clinical practice (9th ed.). Philadelphia, PA: Elsevier/Saunders.
  11. Parker KI et al. A case of apathetic thyroid storm with resultant hyperthyroidism-induced hypercalcemia. Am J Med Sci. 2013 Oct;346(4):338-40.
  12. Poudel RR et al. Apathetic thyrotoxicosis presenting with diabetes mellitus. J Community Hosp Intern Med Perspect. 2014 4(5).
  13. Thiessen, M. (2018). Thyroid and Adrenal Disorders in Rosen's emergency medicine: Concepts and clinical practice (9th ed.). Philadelphia, PA: Elsevier/Saunders.
  14. Thiessen, M. (2018). Thyroid and Adrenal Disorders in Rosen's emergency medicine: Concepts and clinical practice (9th ed.). Philadelphia, PA: Elsevier/Saunders.
  15. Thiessen, M. (2018). Thyroid and Adrenal Disorders in Rosen's emergency medicine: Concepts and clinical practice (9th ed.). Philadelphia, PA: Elsevier/Saunders.
  16. Burch HB, Wartofsky L. Life-threatening thyrotoxicosis. Thyroid storm. Endocrinol Metab Clin North Am. 1993 Jun;22(2):263-77
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  23. Doses based on American Association of Clinical Endocrinologists recommendations
  24. Isozaki O et al. Treatment and management of thyroid storm: analysis of the nationwide surveys: The taskforce committee of the Japan Thyroid Association and Japan Endocrine Society for the establishment of diagnostic criteria and nationwide surveys for thyroid storm. Clin Endocrinol (Oxf). 2016; 84(6):912-8 (ISSN: 1365-2265).
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  27. Weingart, Scott. EMCRIT Thyroid Storm Show Notes. http://emcrit.org/podcasts/thyroid-storm/
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  30. Garg N et al. CALMING THE STORM - ROLE OF PLASMAPHERESIS IN THYROTOXIC CRISES. The Endocrine Society's 95th Annual Meeting and Expo, June 15–18, 2013 - San Francisco.
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