Thyroid Storm

• Precipitating factors: Untreated primary hyperthyroidism (i.e. Grave’s), thyroid surgery, trauma, infection, iodine exposure, amiodarone
• 10-30% mortality

S/Sx:

• Vitals - High fever (104F), tachycardia
• Cardiac - palpitations, DOE, wide pulse pressure, ischemia, afib, heart failure symptoms
• CNS - agitation, delirium, confusion, coma
• GI - nausea, vomiting, diarrhea
• Liver - hepatomegaly, dysfunction/failure, jaundice

Diagnosis is clinical - Burch and Wartofsky scoring system can help

Labs: can see elevated T4 and T3, low TSH, leukocytosis, elevated BUN, elevated transaminases, hypercalcemia, hyperglycemia

Treatment:

Thionamides - blocks new thyroid hormone synthesis, inhibits thyroid peroxidase

• Propylthiouracil (PTU) also decreases peripheral conversion T4 to T3
• 500-1000mg load then 250mg q4h PO
• 400-600mg q6h Rectal
• Methimazole
• 60-120mg per daily in 4-6 doses PO
• 20-40mg q6-8h Rectal
• 10-30mg q6-8h IV

Beta Blocker - nonselective beta-adrenergic antagonist and decrease peripheral conversion of T4 to T3

• Propranolol
• 60-120mg q6h PO
• 0.5-1mg bolus then 1-2mg q15min IV

WAIT 1 HOUR after Thionamides for Iodine (prevent iodine as substrate for new hormone)

Iodine - decrease new hormone synthesis (inhibits iodide binding to thyroglobulin in gland when iodide reach threshold), block release of preformed hormone (inhibits release of T3 and T4 from thyroglobulin)

• SSKI
• 5 drops q6h PO (bad tasting)
• 250-500mg q8h Rectal
• Lugol’s solution
• 8 drops q6h PO
• 5-10 drops q6-8h Rectal
• Lithium (if iodine anaphylaxis) - inhibit T4 and T3 synthesis
• 300mg q6-8h PO (monitor serum levels 0.6-1 mEq/L)

Glucocorticoids - prevent adrenal insufficiency and decrease T4 to T3 peripheral conversion

• 300mg load then 100mg q8h IV

Cholestyramine - inhibits enterohepatic circulation of thyroid hormone by binding to conjugated products and promote excretion

• 1-4g BID PO

AVOID salicylates - can increase free hormone levels (decreases T4 binding to binding globulin)

Reference

Chiha M, Samarasinghe S, Kabaker AS. Thyroid Storm: An Updated Review. Journal of Intensive Care Medicine. 2015;30(3): 131-140. https://doi-org.ezproxy.rowan.edu/10.1177/0885066613498053