Thyrotoxic crisis or thyroid storm is a severe form of hyperthyroidism and a rare endocrinological emergency. The cornerstones of medical therapy in thyroid storm include decreasing the levels of circulating T3 in the blood as well as inhibiting the hormone’s peripheral effects through β-adrenergic blockade. Propranolol is the preferred agent for β-blockade in hyperthyroidism and thyroid storm due to its additional effect of blocking the peripheral conversion of inactive T4 to active form T3. We report a typical clinical scenario where propranolol was administered in treatment of thyroid storm but an uncommon adverse outcome: circulatory failure from cardiogenic shock warranting vasopressor and inotropic support. Caution with regard to the use long-acting β-blocking agents in patients with underling thyrocardiac disease may prevent this life-threatening adverse effect. Ultra–short-acting β-blockers that are easy to titrate maybe a suitable alternative in this subset of patients.

Approximately 10-15% of patients requiring mechanical ventilation will ultimately undergo tracheostomy (2). In a large prospective cohort study, up to 34% of patients who required mechanical ventilation for more than 48 hours needed tracheostomy placement (3). More than half of the patients who underwent tracheostomy also required PEG placement for prolonged nutritional needs (4,5). In this article, we review appropriate post-procedural care for PDT and PEG, as well as possible complications that can develop.

Percutaneous tracheostomy is a commonly performed procedure for patients in the intensive care unit (ICU) and offers many benefits, including decreasing ICU length of stay and need for sedation while improving patient comfort, effective communication, and airway clearance. However, there is no consensus on the optimal timing of tracheostomy in ICU patients. Ultrasound (US) and bronchoscopy are useful adjunct tools to optimize procedural performance. US can be used pre-procedurally to identify vascular structures and to select the optimal puncture site, intra-procedurally to assist with accurate placement of the introducer needle, and post-procedurally to evaluate for a pneumothorax. Bronchoscopy provides real-time visual guidance from within the tracheal lumen and can reduce complications, such as paratracheal puncture and injury to the posterior tracheal wall. A step-by-step detailed procedural guide, including preparation and procedural technique, is provided with a team-based approach. Technical aspects, such as recommended equipment and selection of appropriate tracheostomy tube type and size, are discussed. Certain procedural considerations to minimize the risk of complications should be given in circumstances of patient obesity, coagulopathy, or neurologic illness. Herein, we provide a practical state of the art review of percutaneous tracheostomy in ICU patients. Specifically, we will address pre-procedural preparation, procedural technique, and post-tracheostomy management.

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