FOAMed of the Week: Thyroid Storm Via EMcrit

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Yet more FOAMed gospel from Scott Weingart in NYC. Below is the podcast and show notes, but for the full experience check out the actual site for the comments:  www.emcrit.org/podcasts/thyroid-storm/

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:

Diagnosing Thyroid Storm

From Jonathan LoPresti

  1. Hyperthyroid

  2. Fever

  3. AMS-trouble concentrating all the way to coma

  4. Sympathetic Surge

  5. Precipitating Event

Elderly-internalized beta receptors may have more subtle presentations of storm

 

from JICM 2015;30:131

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)

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

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