Not a topic of specific expertise for me, but I wanted to get all of the info in one place for future use–Thyroid Storm
Most of the Below Information is from:
- PMID 23920160
- EMRAP June 2010 – Stuart Swadron Interviews Jonathan LoPresti
Diagnosing Thyroid Storm
From Jonathan LoPresti
- Hyperthyroid
- Fever
- AMS-trouble concentrating all the way to coma
- Sympathetic Surge
- Precipitating Event
Elderly-internalized beta receptors may have more subtle presentations of storm
Storm Score
- >45 is almost surely storm,
- 25-44 is suggestive,
- <25 is unlikely
(Endocrinol Metab Clin North Am. 1993 Jun;22(2):263-77)
Labs
TSH, Free T3, Free T4
Blood Cultures
May see low Cr and High Ca
Won't mount normal WBC increase in hyperthyroidism
May also have thrombocytopenia
Treatment
Block New Production
The thionamides: Methimazole and PTU; the latter may be preferred as it also blocks peripheral T4 to T3 conversion
PTU 500-1000 mg load then 250 mg Q4 hours (Guidelines from AACE (endo group))
Methimazole 60-80 mg qday, divided into doses q4-6 hrs (20 mg Q6)
Recent Study says they may be equally as effective, but it was not an RCT [Comparison of Propylthiouracil vs Methimazole for Thyroid Storm in Critically Ill Patients. JAMA Netw Open. 2023 Apr 3;6(4):e238655. doi: 10.1001/jamanetworkopen.2023.
Block Thyroid Hormone Release
Wolf-Chaikoff effect blocks iodide binding to thyroglobulin once critical levels of iodide are reached
SSKI 5 drops PO q6
or
Lugol's Solution 8 drops PO q 6
or Sodium Iodide 0.5 mg IV Q 12 hours
Don't give until 60 minutes after thionamides
Lithium can be substituted in patients who will undergo radioactive iodide treatment or patients allergic to Iodides, use 300 mg q 6-8 but personally, I would consult a endocrinologist before going this road. (J Inten Care Med 2015;30(3):131)
Treat Volume Loss
These patients have large insensible losses and diuresis. Even in the setting of seeming heart failure, they may need fluids as the heart failure is high-output.
Treat Sympathetic Surge
- Propanolol 1 mg IV (test dose) then Propranolol 1-2 mg q 15 minutes until HR of 100 bpm
- then start Propanolol drip at whatever dose it took to get IV load control (Max 3-5 mg/hr)
Propranolol also blocks T4 to T3 conversion
or titrate esmolol for HR of 100 bpm, but selective B1 means may be less effective
Update: A listener, @Rx_Ed, sent this article on the pharmacokinetics of propanolol in thyroid storm (
Increased Clearance of Propranolol in Thyrotoxicosis (Ann Intern Med. 1981;94(4_Part_1):472-474. doi:10.7326/0003-4819-94-4-472)
Block Peripheral Conversion and Shield from Adrenal Insufficiency
Dexamethasone 4 mg IV Q 6 hours
or
Hydrocortisone 300 mg IV and then 100 mg q 8 hours
Not Available in the US?
Oral cholecystographic agents (HIDA Scan Contrast) 2g loading dose followed by 1g q day
Temperature regulation
- Do not aggressively cool these patients; this is contraindicated because it can lead to further vasoconstriction
Fix Precipitating Event/Treat Infection
Look carefully, treat aggressively
Cardiomyopathy
Take care with beta-blockers until you do an echo in case there is high-output failure cardiomyopathy
Sim Case
Links on the ‘Crit
Additional New Information
More on EMCrit
EMCrit 190 – Emergencies with a Side of Hypertension(Opens in a new browser tab)
Additional Resources
Professor
Nassau University Medical Center
No conflicts of interest (coi).
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First time I’ve heard of the scoring system, but it seems insensitive b/c the DDx could include sepsis, NMS, SS, cocaine intoxication, pheo, MH crisis, etc (okay a bit of anesthesia slant). The tachycardia/afib can cause a cardiomyopathy as well.
Usually thyroid storm happens a few days after surgery not intraop (unless you’re manipulating the thyroid I suppose).
Mortality in true thyroid storm can be 30%.
and usually pts are discharged home with methimazole instead of PTU b/c of less frequent dosing and better adherence.
Hey Scott, Fantastic Podcast as always……I had just a few minor thoughts….. 1. If I recall correctly the biggest reason these patients die is high output heart failure from sympathetic surge so the mainstay of treatment is still beta blockade (i.e. propranolol) in addition to the other treatments you mentioned. 2. I always consult endocrine before giving iodine containing solutions because they may want to do a RAIU or RAI and this will interfere with that test or treatment respectively. 3. Finally, maybe not important in the acute setting, but patients are more compliant with methimazole due to decreased dosing,… Read more »
I have had a couple of these already come to my ICU. Besides the tx you discuss, I have had fantastic results with precidex also. It really makes the patient comfortable and helps normalize their vitals…. Clinically it’s almost as if it’s synergistic with all the other treatments.
Interesting… is there literature on this already? What kind of doses are you using?
I think there is some talk in the anesthesia world about it but the way I think of it is analagous to the way I use dex for alcohol withdrawal…. Namely, it normalizes the patients vitals and essentially attenuated the effect of your other treatments. The way I dose it is the way I dose it in any other ICU patient. I never load as a personal practice. Start at 0.2 mcg/kg/hour and go up 0.1-0.2 every 10-15 minutes until the patient is either comfortable (rass 0- -1) OR the HR is below 80. In event of hypotension or bradycardia,… Read more »
Excellent podcast on a topic that gets little coverage. One thing to add is that the treatment of patients with exogenous thyroid hormone causing thyroid storm is a bit different. Here, there is no issue of overproduction or oversecretion and so blocking production and secretion isn’t necessary. Although there’s no evidence, there is the theoretical harm that blocking synthesis could hurt the patient after resolution of the storm as it may suppress normal function (unlikely that a dose or two would do this). If the patient took exogenous T4 (i.e. levothyroxine) you should definitely suppress the peripheral effects with beta… Read more »
perfect, brother. Had meant to mention that and totally forgot.
Thanks for the interesting talk,
Something that struck me was how similar the clinical presentation of thyroid storm is to a stimulant overdose. Does anyone have thoughts on concerns with using beta blockers if cocaine overdose is still in the DDx? Obviously a good hx is always important.
~Tom Hays, Mount Sinai Pediatrics, PGY1
Scott… fantastic podcast as usual.. a few thoughts.. As someone who “suffers” from hypothyroidism, and takes levothyroxine daily, and who works a long clinical schedule as a medic… I’ve screwed up my dosing before due to exhaustion, and one day blending into the next. The levothyroxine I take is 125mcg/day…it’s not a huge dose, but, I’ve doubled it accidentally a few times. Usually the afternoon after the second dose is the worst… hypoglycemia, sweating, palpitations, tachycardia, confusion, nausea, fever….. it seriously sucked… I really don’t recommend it. For me, one additional dose was a tipping point, but, it doesn’t appear… Read more »
Scott, thanks for this review. WikEM has had a great review and guide list for awhile on this topic http://www.wikem.org/wiki/Thyroid_storm which I have used for the two thryoid storm patients I have seen. Here in montana where I do locums work we have a thryoid clinic and it never fails that once a year we get one or two in the ED. I added a few of your points to the wiki so that everyone can benefit. This way next time I am without internet in montana I’ll have your words of wisdom offline on my phone. Thanks again for… Read more »
thanks, Jeff!
Thanks for this AMAZING talk,
I would like to add one point, and plz correct me if I am wrong. When we have a patient with contraindication for beta blockers we can give either guanethidine or reserpine.
Thanks again.
absolutely!
Thank you we benefited from this FOAMed here in Southern Egypt today
Perhaps around the guilt hypothyroidism? hypothyroidism the General condition of the body caused by deficiency of thyroid hormones, which is more common in women. It is difficult to diagnose it, since the disease is almost asymptomatic. Often, when we feel drowsiness, lethargy, joint pain, write off everything for beriberi or fatigue. Thyroid hormones affect the work of absolutely all organs, so it is important to identify the problem in a timely manner and begin treatment with an endocrinologist.