Dr.

Supreet Singh Nayyar, AFMC

2012

Thyroid Storm

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Acute, life-threatening, hypermetabolic state induced by excessive release of thyroid hormones (THs) in individuals with thyrotoxicosis A decompensated state of thyroid hormoneinduced, severe hypermetabolism involving multiple systems and is the most extreme state of thyrotoxicosis

Epidemiology Mortality o Adult mortality rate is extremely high (90%) if early diagnosis is not made and the patient is left untreated o With early management 20% Sex F : M :: 3-5 : 1

History

General symptoms o Fever o Profuse sweating o Poor feeding and weight loss o Respiratory distress o Fatigue GI symptoms o Nausea and vomiting o Diarrhea o Abdominal pain o Jaundice Neurologic symptoms o Anxiety (more common in older adolescents) o Altered behavior o Seizures, coma Physical

Fever Temperature consistently exceeds 38.5C. Patients may progress to hyperpyrexia. Temperature frequently exceeds 41C. Excessive sweating Cardiovascular signs o Hypertension with wide pulse pressure o Hypotension in later stages with shock o Tachycardia disproportionate to fever o Signs of high-output heart failure o Cardiac arrhythmia (Supraventricular arrhythmias are more common, [eg, atrial flutter and fibrillation], but ventricular tachycardia may also occur.) Neurologic signs o Agitation and confusion o Hyperreflexia and transient pyramidal signs o Tremors, seizures
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Dr. Supreet Singh Nayyar, AFMC o Coma Signs of thyrotoxicosis o Orbital signs o Goiter

2012

Causes

Thyroid storm is precipitated by the following factors in individuals with thyrotoxicosis: o Sepsis o Surgery o Anesthesia induction o Radioactive iodine (RAI) therapy o Drugs (anticholinergic and adrenergic drugs such as pseudoephedrine; salicylates; nonsteroidal anti-inflammatory drugs [NSAIDs]; chemotherapy) o Excessive thyroid hormone (TH) ingestion o Withdrawal of or noncompliance with antithyroid medications o Diabetic ketoacidosis o Direct trauma to the thyroid gland o Vigorous palpation of an enlarged thyroid o Toxemia of pregnancy and labor in older adolescents; molar pregnancy

Pathophysiology

Although the exact pathogenesis of thyroid storm is not fully understood, the following theories have been proposed: o Patients with thyroid storm reportedly have relatively higher levels of free thyroid hormones possibly released due to handling of thyroid o Adrenergic receptor activation increased sympathetic activity o Drop in binding protein levels, which may occur postoperatively o Alterations in tissue tolerance to thyroid hormones as a result of surgery

Laboratory Studies Thyroid storm diagnosis is based on clinical features, not on laboratory test findings Thyroid studies CBC count: mild leukocytosis Liver function tests (lfts): Non specific elevated enzymes ABG

Management

Treated in an ICU setting Close monitoring Supplemental oxygen Ventilatory support Rehydration with intravenous fluids Dextrose solutions preferred to cope with continuously high metabolic demand Correct electrolyte abnormalities
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Dr. Supreet Singh Nayyar, AFMC

2012

Treat cardiac arrhythmia, if necessary Aggressively control hyperthermia by applying ice packs and cooling blankets and by administering paracetamol (15 mg/kg orally or rectally every 4 h) Promptly administer antiadrenergic drugs (eg, propranolol, labetalol, esmolol) to minimize sympathomimetic symptoms Correct the hyperthyroid state. Administer antithyroid medications to block further synthesis of thyroid hormones (THs). High-dose propylthiouracil (PTU) is preferred because of its early onset of action and capacity to inhibit peripheral conversion of T4 to T3 Administer iodine compounds (Lugol iodine - Contains 100 mg potassium iodide and 50 mg iodine; provided 8 mg iodide/drop, 20 drops per ml) orally or via a nasogastric tube to block the release of THs (at least 1 h after starting antithyroid drug therapy) If available, intravenous radiocontrast dyes such as ipodate and iopanoate can be effective in this regard. These agents are particularly effective at preventing peripheral conversion of T4 to T3. Administer glucocorticoids to decrease peripheral conversion of T4 to T3. This may also be useful in preventing relative adrenal insufficiency due to hyperthyroidism. Treat underlying condition, if any, that precipitated thyroid storm and exclude comorbidities such as diabetic ketoacidosis and adrenal insufficiency Infection should be treated with antibiotics Rarely, as a life-saving measure, plasmapheresis has been used to treat thyroid storm in adults

Prevention Perform surgery in thyrotoxic patients only after appropriate thyroid and/or beta-adrenergic blockade.

Prognosis If untreated, thyroid storm is almost invariably fatal With adequate thyroid-suppressive therapy and sympathetic blockade, clinical improvement should occur within 24 hours Adequate therapy should resolve the crisis within a week Treatment for adults has reduced mortality to less than 20%

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