DO NOT wait for TSH, T4, T3

○ This is a clinical diagnosis and you must be able to tell thyrotoxicosis from thyroid storm and immediately pull the trigger on management.

○ Very little to no downside if you’re wrong but universally fatal if untreated.

○ TSH may not be low early in disease course

○ Consider Burch-Wartofsky scale to help diagnosis

Aggressively search for and treat the underlying trigger → sepsis v. trauma v. MI v. CHF v. PE v. DKA v. burns v. pregnancy

Have a low threshold to start antibiotics as sepsis and thyroid storm have considerable overlap.

Beware of aggressive cooling → patient’s vasodilate to deal with hyperthermia and aggressive cooling takes away this compensatory mechanism and can lead to shivering and heat production.

Beware of how you treat heart failure in these patients → this is high output failure where the HR is too fast for the heart to fill in diastole.

○ Controlling the HR is the best management

○ Don’t be afraid to fluid resuscitate as these patients need the preload and to recover insensible losses.

○ Diuresis can be dangerous.

Fear of cardiovascular collapse leading to less aggressive use of propranolol.

○ Half-life is 5 minutes so very titratable

○ Propranolol is essential to decrease sympathetic hyperactivity and partially block T4 → T3 conversion.

○ If BP bottoms out, can give IV fluids which these patients need because of insensible losses from hyperthermia and hypermetabolic state.

○ While beta-blockers are a heart failure contraindication, this is a high output cardiac failure

Don’t give Lugol’s solution or SSKI too early → will worsen thyroid storm.

The elderly patient is more subtle → will likely have single organ dysfunction (afib/CHF or altered mental status) but lack the sympathetic surge

References

1. Cline DM, Ma OJ, Cydulka RK, Meckler GD, Handel DA, Thomas SH. Tintinalli’s Emergency Medicine, Seventh Edition. 2012; 131:637-640.

2. Nayak B, Burman K 2006 Thyrotoxicosis and thyroid storm. Endocrinol Metab Clin North Am 35:663–686.

3. Burch HB, Wartofsky L. Life-threatening thyrotoxicosis. Thyroid storm. Endocrinol Metab Clin North Am 1993;22:263–7