Thyroid storm

Background

Precipitating events:

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

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

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