Thyroid storm: Difference between revisions
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=== Precipitants === | === Precipitants === | ||
*Infection | *Infection | ||
*Trauma | *Trauma | ||
*Recent thyroid manipulation (physical or surgical) | |||
*[[Burns]] | |||
*Surgery | *Surgery | ||
*[[DKA]] | *[[DKA]] | ||
| Line 14: | Line 16: | ||
*[[CVA]] | *[[CVA]] | ||
*[[PE]] | *[[PE]] | ||
*Interferon treatment | |||
*Molar Pregnancy | |||
*[[Hypoglycemia]] | |||
*Withdrawl of antithyroid treatment | |||
*Exposure to iodine (or iodinated contrast) | |||
==Clinical Presentation == | ==Clinical Presentation == | ||
Revision as of 12:31, 24 May 2015
Background
- Mortality
- Without treatment: 80-100%
- With treatment: 15-50%
Precipitants
- Infection
- Trauma
- Recent thyroid manipulation (physical or surgical)
- Burns
- Surgery
- DKA
- Withdrawal of thyroid medication
- Iodine administration
- MI
- CVA
- PE
- Interferon treatment
- Molar Pregnancy
- Hypoglycemia
- Withdrawl of antithyroid treatment
- Exposure to iodine (or iodinated contrast)
Clinical Presentation
- Classic Triad:
- Hyperthermia
- Tachycardia
- AMS
- May also have:
- CHF
- Palpitations
- Dyspnea
- Increased pulse pressure
- A-fib
Differential Diagnosis
- Infection
- Sympathomimetic ingestion (cocaine, amphetamine, ketamine)
- Heat Exhaustion
- Heat Stroke
- Delirium tremens
- Malignant Hyperthermia
- Malignant Neuroleptic Syndrome
- Hypothalamic stroke
- Pheochromocytoma
- Medication withdrawal (cocaine, opioids)
- Psychosis
- Organophosphate Poisoning
Diagnosis
Work-Up
- Chemistry
- CBC
- TSH/Free T3/T4
- Cortisol level (rule-out concurrent adrenal insufficiency)
- ECG
- Rule-out infection:
Burch & Wartofsky Diagnostic Criteria
| Category | Points | ||||
| Thermoregulatory dysfunction (Temperature) | |||||
|---|---|---|---|---|---|
| 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, n/v, abd 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 (pulm edema, A. fib) | 15 | ||||
| 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]
Identify precipitant (i.e. med noncompliance, DKA, infection)
Supportive care
- Fever
- Cooling measures (ice packs & cooling blankets)
- Acetaminophen (avoid aspirin or NSAIDS because they displace thyroid hormone from TBG)
- Dehydration/hypoglycemia
- D5NS (most pts have depleted glycogen stores)
- Cardiac decompensation (CHF, A-fib)
- Rate control, inotropes, diuretics as needed (short acting always better)
- Agitation
- Benzodiazepines are the preferred agent
Decrease Peripheral Hormone Conversion
can use PO or IV Propranolol
- Propranolol PO 60-80 q4hr (if pt can tolerate PO)
- Propranolol IV 1-2mg over 10 min; if tolerates then 1-3mg boluses q3hr OR
- Contraindications are same as for other medical conditions (e.g. CHF, Reactive Airway Disease, see alternative therapies)
- Non-Selective benefits of B-Blockade (improve tremor, hyperpyrexia, agitation)
Block New Hormone Synthesis
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 600-1000 mg PO or PR followed by 200-250mg q4hr
- Note black box warning of hepatotoxicity so check LFTs prior
- Avoid in patients with significant liver disease; use methimazole instead
- Methimazole 20-25mg q4hr
- Longer acting than PTU
- Should be avoided in pregnancy by classic teaching (Freely crosses placenta, birth defects)
If contraindication or previous toxicity to thionamide therapy, then can consider:
- 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.
Other Therapies
- Esmolol 250-500mcg/kg loading dose, then 50-100mcg/kg/min
- B1 selective so can be used in pt with active CHF, asthma, etc.
- Potassium iodide (SSKI)
- Give 1hr after PTU to prevent increased hormone production (Jod-Basedow effect)
- 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 250 mg) orally every 6 hours
- Avoid potassium iodide if patient is on amiodarone
- Can substitute radiocontrast dyes (Iopanoic acid, ipodate and iopanoate) or oral lugol solution
- Lithium carbonate[2]
- 300mg q6hr
- Consider if iodine allergic
Adrenal Insufficiency Treatment
Often there may be associated adrenal insufficiency (also blocks T4>T3)
- Hydrocortisone 100-300mg IV bolus, followed by 100mg q8hr OR dexamethasone 2mg IV q6hr
Disposition
- Admission to ICU
See Also
Sources
- ↑ American Thyroid Association Treatment Recomendations http://www.thyroid.org/thyroid-guidelines/hyperthyroidism/resultsh/
- ↑ Carroll R, Matfin G. Endocrine and metabolic emergencies: thyroid storm. Ther Adv Endocrinol Metab. 2010 Jun; 1(3): 139–145. Full Text