Thyroid storm: Difference between revisions

(Created page with "==Background== Inciting causes: 1) graves 2) goiter 3) thyroiditis 4) iatrogenic wolff-chaikoff effect: increased iodine concentration leads to transient decrease of T3...")
 
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Inciting causes:
Precipitating events:
 
1) graves
 
2) goiter
 
3) thyroiditis
 
4) iatrogenic
 
 
wolff-chaikoff effect: increased iodine concentration leads to transient decrease of T3/T4


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


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Classic Triad: hyperthermia, tachycardia, AMS
* Triad: Hyperthermia, Tachycardia, AMS
 
   
  Burch & Wartofsky Criteria


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


99-99.9 5
99-99.9 5
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III. Gastrointestinal-hepatic dysfunctionModerate (diarrhea, n/v,  abd pain) 10
III. Gastrointestinal-hepatic dysfunction Moderate (diarrhea, n/v,  abd pain) 10
Severe (unexplained jaundice) 20
Severe (unexplained jaundice) 20
   
   


IV. Cardiovascular dysfunction (tachycardia)99-109 5
IV. Cardiovascular dysfunction (tachycardia) 99-109 5
110-119 10
110-119 10
120-129 15
120-129 15
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V. Congestive heart failureMild (pedal edema) 5
V. Congestive heart failure Mild (pedal edema) 5
Moderate (bibasilar rales) 10
Moderate (bibasilar rales) 10
Severe (pulm edema, A. fib) 15
Severe (pulm edema, A. fib) 15
   
   


VI. Precipitant historyNegative 0
VI. Precipitant history Negative 0
Positive 10
Positive 10
   
   
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Scoring
Scoring


>45 = highly suggestive
>45 = Highly suggestive of thyroid storm


25-44 = supports diagnosis
25-44 = Suggestive of impending storm


<25 = unlikely
<25 = Unlikely to represent storm


   
   
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* High dose PTU
* Block new hormone synthesis
* Beta blockers
* PTU 600-1000 mg PO or PR followed by 200-250mg q4hr
* Corticosteroids
* Preferred to methimazole b/c also blocks T4>T3 conversion
* + Inorganic iodine (1 hour after PTU)
* Methimazole 20-25mg q4hr
  ==Disposition==
* Longer acting than PTU
 
* Block hormone release
 
* Wolff-Chaikoff effect: increased iodine concentration leads to transient decrease of T3/T4
Admit
*  Potassium iodide 5 gtt q6hr (Give 1hr after PTU)
 
* 1st line
* Lithium 300mg q6hr
 
* Consider if iodine allergic
==See Also==
* 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==




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




Revision as of 23:43, 1 March 2011

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

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