Thyroid Storm Case Study
-Develop knowledge of the etiologies,
manifestations, and treatment of
endocrine and metabolic disorders.
-Demonstrate understanding of the
common endocrine abnormalities,
especially regarding presentation,
initial evaluation and management,
and disposition.
Presentation
• The patient is a young, otherwise healthy woman
accompanied by her husband with a history of Graves
Disease, diagnosed three months prior. The husband
has brought her into the Emergency Department from
home due to what he thinks is a “severe panic attack.”
The patient is visibly jittery, crying, upset. She reports a
lack of sleep. She does appear extremely anxious.
• The patient has become pregnant and has not as yet had
her first prenatal visit. She has been non-complaint with
her medication methimazole, due to her concerns over
the medication’s effect on her pregnancy.
Physical Assessment:
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Tachycardia
Atrial Fibrillation (irregular rapid pulses)
Hypertension
Rales
• What else do you want?
180/110
170
94%
RR up to 30
CBC, chem panel normal
TSH
<0.002
B Blocker treatment
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Complications:
intrauterine growth retardation,
prolonged labor,
neonatal bradycardia,
hypotension,
hypoglycemia,
prolonged hyperbilirubinemia,
evaluate the risk-to-benefit analysis [4]
Consider:
Esmolol (cardioselective)
Metoprolol
Atenolol
Propranolol
Assessment
• History patient gives: been nervous, etc. for the
past week, with symptoms worsening
• Patients initial exam: febrile, agitated, diarrhea ,
• Patients physiology: sinus tachychardic, soft and
smooth skin
Assessment
• Discussion with patient reveals that she has not
been overly concerned about her Grave’s disease,
she only came to the hospital because she is
trying to get pregnant and doesn’t want to be
sick, doesn’t take her medicine because she
thinks it will decrease her chances of getting
pregnant
• CT chest reveals thickened left ventricle
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Burch and Wartofsky Predictive Clinical Scale for
Thyroid Storm
Parameter taken into consideration
Scoring Points
Thermoregulatory dysfunction
Temperature (Oral, ºF)
99-99.9
5
100-100.9
10
101-101.9
15
102-102.9
20
103-103.9
25
>104
30
CNS Effects
Absent
0
Mild (agitation)
10
Moderate (delirium, psychosis, extreme lethargy)
20
Severe (seizures, coma)
30
GI-hepatic dysfunction
Absent
0
Moderate (diarrhea, nausea, vomiting, abdominal pain)
10
Severe (unexplained jaundice)
20
Tachycardia (beats/min)
99-109
5
110-119
10
120-129
15
130-139
20
>140
25
Congestive Cardiac Failure
Absent
0
Mild (pedal edema)
5
Moderate (bibasal rales)
10
Severe (pulmonary edema)
15
Atrial Fibrillation
Absent
0
Present
10
Precipitating Events
Absent
0
Present
10
≥45: highly suggestive of thyroid storm
25-44: suggestive of impending storm
<25: unlikely to represent thyroid storm
Pathophysiology
• Hyperthyroidism includes diseases that are a
subset of thyrotoxicosis that are caused by
excess synthesis and secretion of thyroid
hormone by the thyroid. These diseases are not
associated with exogenous thyroid hormone
intake or subacute thyroiditis. (See Etiology.)
• Thyrotoxicosis is the hypermetabolic condition
associated with elevated levels of free thyroxine
(FT4) and/or free triiodothyronine (FT3).
Treatments
• Many of the neurologic and cardiovascular
symptoms of thyrotoxicosis are relieved by betablocker therapy. Prior to therapy, examine the
patient for signs and symptoms of dehydration
that often occur with hyperthyroidism. After oral
rehydration, beta-blocker therapy can be started.
Do not administer beta-blocker therapy to a
patient with a significant history of asthma.
Calcium channel blockers can be used for the
same purposes when beta blockers are
contraindicated or poorly tolerated.
• Antithyroid Drugs
• Antithyroid drugs (eg, methimazole, propylthiouracil) have been used for
hyperthyroidism since their introduction in the 1940s. They are employed
for the long-term control of hyperthyroidism in children, adolescents, and
pregnant women (propylthiouracil only for pregnancy). In women who are
not pregnant, the medications are used to control hyperthyroidism prior to
definitive therapy with radioactive iodine. In surveys of thyroid specialists
in the United States, the preferred treatment of hyperthyroidism is
radioactive iodine therapy.
• Antithyroid medications inhibit the formation and coupling of
iodotyrosines in thyroglobulin, which are necessary for thyroid hormone
synthesis, leading to a gradual reduction in thyroid hormone levels over 2-8
weeks or longer. A second therapeutic action of propylthiouracil, but not
methimazole, is the inhibition of conversion of T4 to T3. T3 is a more
biologically active form of thyroid hormone. A quick reduction in T3 is
associated with a clinically significant improvement in thyrotoxic
symptoms.
• Titrate the antithyroid drug dose every 4 weeks until thyroid functions
normalize. Some patients with Graves disease go into a remission after
treatment for 12-18 months, and the drug can be discontinued. Notably,
half of the patients who go into remission have a recurrence of
hyperthyroidism within the following year. Nodular forms of
hyperthyroidism (toxic multinodular goiter and toxic adenoma) are
permanent conditions and will not go into remission.
• The drug of choice for hyperthyroidism in the nonpregnant woman
is methimazole. The recent US Food and Drug Administration
(FDA) boxed warning for increased liver failure with
propylthiouracil has limited its use to just the first trimester of
pregnancy. Methimazole has rarely been associated with cloacal and
scalp (cutis aplasia) abnormalities when given during early
gestation. Generally, if a women desires pregnancy, the patient is
switched to propylthiouracil. After the 12 weeks of gestation, the
patient is switched back to methimazole. Methimazole is a more
potent and longer-acting drug. Often, patient compliance is better
with methimazole taken once or twice daily than with
propylthiouracil given 3-4 times daily.
• Propylthiouracil is still the drug of choice in uncommon situations
of life-threatening severe thyrotoxicosis because of the additional
benefit of inhibition of T4 -to-T3 conversion. Administer
propylthiouracil every 6-8 hours. The reduction in T3, which is 20100 times more potent than T4, theoretically helps to reduce the
thyrotoxic symptoms more quickly than does methimazole. Once
thyroid levels are decreasing toward normal, the patient can be
switched to methimazole therapy.
Should we give the B blocker?
• Consider the risks/benefits…
We have given a B Blocker and restarted her methimazole. Vital signs
have improved
• Give an SBAR to the floor…