
44 y/o patient with Graves’ Dx

Recently cleared for total thyroidectomy

The surgical H&P:
 AF VSS WNL RRR no m/r/g CTAB
Vitals: 101.9 167 153/86 26
 Agitation
 Scleral icterus
 Bilateral crackles with expiratory wheezing
 Palpitations
 Mild diaphoresis and nausea without emesis
 No obstruction of airway 2 /2 goiter

Thyrotoxic vs. Thyroid Storm
 Life-threatening complication

 Mortality with Tx 8% or below

Most cases occur post-op
 Within 6-18 hrs
 Why? Pre-op Tx necessary?

Si/Sx varied but consider…
 Hyperdynamic Metabolism
SITT DD are common triggers
 Burch and Wartofsky Score

 ≥ 45 highly suggestive of thyroid
storm
 ≤ 25 thyroid storm unlikely

Temp:
 99-99.9
 100-100.9
 ≥ 104.0

90-109
110-119
120-129
≥140

5 points
10 points
15 points
25 points

0 points
10 points

Precipitating Event
 Absent
 Present
0 points
10 points
Absent
0 points
Mild (pedal edema) 5 points
Moderate (bb rales) 10 points
Severe(pulm edema) 15 points
CNS




A. Fib
 Absent
 Present
CHF




5 points
10 points
30 points
Tachycardia






Absent
Mild
Moderate
Severe
0 points
10 points
20 points
30 points
GI-Hepatic
 Absent
 Moderate
 Severe
0 points
10 points
20 points

Pre-op euthyroidism
 Goiter?
 Patients with tachycardia and HTN  consider cancellation

Iodide
 Sodium Iodide, Iopanoic acid, Lugol’s solution
○ Block the release of hormone
○ Wolff-Chaikoff effect


Beta-Blocker
Cortisol
 Adrenal function?

Thionamides
 PTU favored for decrease in peripheral conversion



Cholestyramine
Temp control
Hydration
 With or without glucose?

Nerve damage
 Superior Laryngeal
○ Motor to Cricothyroid mm. 
aspiration
 Recurrent Laryngeal
○ Everything laryngeal except
Cricothyroid  Hoarseness,
stridor, total airway
obstruction

Hypoparathyroidism
 Laryngospasm


Hypothyroidism
Tracheal Compression





“Big Blue”
Nayak B., Burman K.: Thyrotoxicosis and Thyroid Storm.
Endocrinology and Metabolism Clinics 35. (4): 2006.
Pearce E., Braverman L.: Hyperthyroidism: advantages and
disadvantages of medical therapy. Surgical Clinics of North America
84. (3): 2004.
Franklyn JA.: The Management of Hyperthyroidism. New England
Journal of Medicine 330 (24): 1731-8. 1994 abstract.
Burch H.B., Wartofsky L.: Life-threatening thyrotoxicosis. Thyroid
Storm. Endocrinology and Metabolism Clinics of North America 22:
263-277. 1993. abstract.