Thyrotoxic Storm

Abstract

Stathatos N, Wartofsky L. Thyrotoxic storm. J Intensive Care Med 2002;17:1–7. Thyrotoxic storm is a syndrome of exaggerated thyrotoxicosis with systemic decompensation seen in 1–2% of hospital admissions for thyrotoxicosis. The diagnosis is based on recognition of typical cardinal manifestations, but even when diagnosed and treated, mortality rates are high. Results of thyroid function tests may be no more abnormal than those seen in uncomplicated thyrotoxicosis. Often, there is a history of partially treated thyrotoxicosis, and/or decompensation related to a precipitating event such as infection, stroke, pulmonary embolism, or radioiodine therapy. Treatment must be aggressive and includes volume repletion with i.v. glucose and saline, and pressor agents may be needed. Patients belong in an intensive care unit, with a cooling blanket for hyperpyrexia. Appropriate cardiac medications are employed to control ventricular rate in those with atrial fibrillation. The thyroid is blocked by large doses of antithyroid agent. In patients unable to swallow, tablets can be crushed and given by nasogastric tube or per rectum. After antithyroid drugs are started, stable iodine as Lugol's solution is given to block further hormone release from the gland. Sodium ipodate can be used instead of iodine and has the advantage of inhibiting conversion of T4 to T3. In severe cases, thyroid hormone may be removed from the circulation by peritoneal dialysis or plasmapheresis, and cholestyramine resin may be used to bind T4 and T3 within the gastrointestinal tract. β‐adrenergic antagonists such as propranolol are given, or the very short‐acting β‐adrenergic blocker, esmolol, has also been used with success. A Swan‐Ganz catheter is used to monitor central hemodynamics, especially in patients receiving high‐dose propranolol, pressors, digoxin, diuretics, and fluids. Large doses of dexamethasone have been given based on presumed increased glucocorticoid requirements in thyrotoxicosis and because adrenal reserve may be reduced. Therapy must be continued until a normal metabolic state is achieved, at which time iodine is progressively withdrawn and plans made for definitive treatment.

Post Coronary Artery Bypass Graft (CABG) Surgery Thyroid Storm: A Near Miss

“…Propranolol is the most commonly used beta-blocker in this setting due to its non-selective beta blocking property and decreased conversion of T4 to T3 in the periphery (3,6). Doses as high as 60 mg to 120 mg every 6 hours, with appropriate adjustment for heart rate and blood pressure, may be required due to increased drug metabolism in thyroid storm (16). Regarding the use of anti-thyroid drugs there is no strong data showing clinical benefit of a specific thionamide agent over another, but in the acute setting, propylthiouracil is generally used.…”

Thyroid Storm

“…Hypercalcemia can exist due to the high bone resorption that accompanies hyperthyroidism and can exacerbate dehydration. Finally, glucose levels can be affected by thyroid storm with hyperglycemia due to a combination of increased catecholamine inhibition of insulin release and increased gluconeogenesis 7 or rarely hypoglycemia. 32…”

“…The recommended dose can be as high as 60 to 120 mg orally every 6 hours in view of increased drug metabolism in storm. 7 For a more rapid effect, β-blockade can be accomplished intravenously with propranolol or a shorter acting β-blocker such as esmolol. The IV propranolol should be dosed 0.5 to 1.0 mg slow IV push for an initial dose and then 1 to 2 mg at 15-minute intervals while monitoring the heart rate carefully on telemetry.…”

Thyroid storm: does this syndrome really exist in cats?

“…In human hyperthyroid patients, it is not possible to distinguish those with thyroid storm from those with uncomplicated thyrotoxicosis on the basis of routine laboratory or thyroid function tests. 7 Rather, the diagnosis is a clinical one based on the identification of signs that point to decompensation of a number of organ systems. Manifestations characteristic of thyroid storm include high fever/hyperthermia (a near universal finding) 6,8–10 and central nervous system (CNS) signs varying from marked agitation, delirium, mania and confusion to stupor, obtundation and even coma (CNS signs are second only to fever as a major sign of storm).…”

“…Manifestations characteristic of thyroid storm include high fever/hyperthermia (a near universal finding) 6,8–10 and central nervous system (CNS) signs varying from marked agitation, delirium, mania and confusion to stupor, obtundation and even coma (CNS signs are second only to fever as a major sign of storm). 6–8,10,11 In thyroid storm, the typical cardiovascular findings of mild-to-moderate tachycardia associated with uncomplicated hyperthyroidism may be supplanted by severe, accelerated tachycardia, often with arrhythmias or congestive heart failure. 6,9 Other multiorgan dysfunction common in thyroid storm includes gastrointestinal dysfunction (severe nausea, profuse vomiting, severe diarrhea) and, in severe cases, hepatic failure with jaundice.…”