Thyroid storm, also known as thyrotoxic crisis, is an acute, life-threatening complication of hyperthyroidism.
Thyroid storm also known as thyrotoxic crisis is an acute life-threatening complication of hyperthyroidism it is an exaggerated presentation of thyrotoxicosis and is characterized by compromised organ function whilst rare in the modern era the mortality rate remains high 80 to 100 without treatment even with treatment the mortality rate is between 10 and 50 percent
Prompt consideration of this endocrine emergency with specific treatments can improve outcomes superimposed precipitating factors cause thyroid storm in patients with diagnosed or undiagnosed hyperthyroidism it is more common with graves disease but can occur with other etiologies of hyperthyroidism for example toxic multinodular goiter and toxic adenoma of the
Thyroid the precipitating factors are abrupt discontinuation of anti-thyroid medicine thyroid and non-thyroid surgery trauma acute illness-like infections diabetic ketosidosis acute myocardial infarction cardiovascular accident cardiac failure drug reaction parturition recent use of iodinated contrast medium radioiodine therapy burns stroke medication side effect
Like amiodarone anesthetics salicylates the precipitating factor as mentioned before is always required to cause thyroid storm those precipitating factors cause a rapid increase in thyroid hormone levels which is responsible for the incidence of thyroid storm the hyperactivity of the sympathetic nervous system with increased response to catecholamine along with
An increased cellular response to thyroid hormone during acute stress or infections causing cytokines release and altered immunological disturbances or other possible mechanisms of thyroid storm presentation of thyroid storm is an exaggerated manifestation of hyperthyroidism with the presence of an acute precipitating factor fever cardiovascular involvement
Including tachycardia heart failure arrhythmia central nervous system manifestations and gastrointestinal symptoms are common fever of 104 to 106 degrees with diaphoresis is a key presenting feature cardiovascular manifestations include tachycardia more than 140 beats per minute heart failure with pulmonary edema and peripheral edema hypotension arrhythmia
And death from cardiac arrest central nervous system involvement includes agitation delirium anxiety psychosis or coma gastrointestinal symptoms include nausea vomiting diarrhea abdominal pain intestinal obstruction and acute hepatic failure the diagnosis of thyroid storm needs clinical suspicion based on the presentation mentioned before in a patient with
Hyperthyroidism or suspected hyperthyroidism one should not wait for lab results before starting treatment thyroid function tests can be obtained which usually show high ft4 or ft3 and low tsh it is not necessary to have a very high level of thyroid hormone to cause thyroid storm other lab abnormalities may include hypercalcemia hyperglycemia due to inhibition
Of insulin release and increased glycogenolysis abnormal liver function tests high or low white blood cell count in 1993 the following scoring system for the diagnosis of thyroid storm was introduced temperature 5 points per 1 degree above 99 degrees maximum 30 points central nervous system dysfunction 10 points for mild for example agitation 20 for moderate
For example delirium psychosis or extreme lethargy and 30 for severe for example seizure or coma tachycardia 5 points for 99 to 109 beats 10 points for 110 to 119 beats 15 points for 120 to 129 beats 20 points for 130 to 139 beats and 25 points for beats greater than 140 presence of atrial fibrillation 10 points heart failure 5 for mild like pedal edema 10 for
Moderate like by basilar rails 15 for severe like pulmonary edema gastrointestinal dysfunction 10 for moderate like diarrhea nausea vomiting or abdominal pain and 20 for severe like unexplained jaundice presence of precipitating factor 10 points now diagnosis a total score of more than 45 is highly suggestive of thyroid storm 25 to 44 supports the diagnosis and
Less than 25 makes the diagnosis unlikely treatment of thyroid storm consists of supportive measures like intravenous fluids oxygen cooling blankets acetaminophen as well as specific measures to treat hyperthyroidism if any precipitating factors for example infection are present that needs to be taken care of patients with thyroid storm must be admitted to the
Intensive care unit with close cardiac monitoring and ventilatory support if needed specific strategic steps for treatment therapy to control increased adrenergic tone beta blocker therapy to reduce thyroid hormone synthesis theonamide therapy to reduce the release of thyroid hormone iodine solution therapy to block peripheral conversion of t4 to t3 iodinated
Radio contrast agent glucocorticoid propylthiouracyl propranol therapy to reduce enterohepatic recycling of thyroid hormone bile acid sequestrant after initial supportive measures a beta blocker should be started for any case of suspected thyroid storm typically propranolol 40 to 80 milligrams is given every four to six hours then either a loading dose of propyl
Thio uracil 500 to 1000 milligrams followed by 250 milligrams every four hours or methymazole 20 milligrams every four to six hours should be given an hour after the administration of propyl thio uracil or methymazole give five drops of supersaturated potassium iodide by mouth every six hours always administer theonomide before starting iodine solution therapy
This prevents the imminent increase in thyroid hormone synthesis due to increased iodine load from supersaturated potassium iodide if available oral colisterum and four grams four times daily can be started for severe cases one should look for precipitating factors and treat them accordingly in the first 24 hours of treatment propylthiouracil decreases t3 level
By 45 percent but methimazole drops t3 level by only 10 to 15 percent methymazole whereas causes more rapid normalization of serum t3 level after a few weeks of treatment and it has less hepatotoxicity compared to propyl thiouracil therefore after initial stabilization we should treat with methymazole if propyl thiouracyl was started at the beginning it should
Be changed to methimazole once patient’s clinical conditions improve the iodine solution should be stopped glucocorticoids can be tapered and stopped and beta blocker should be adjusted deonomite therapy should be titrated and if propylthiouracil is used initially it should be switched to methimazole patients should be recommended for definitive treatment
With radioiodine therapy or thyroidectomy if the anamide therapy is contraindicated because of an allergic reaction thyrodectomy is needed after treatment with a beta blocker hydrocortisone cholesterol and iodine solution plasmapheresis is the last resort if all other measures fail surgery may be required in patients with graves disease for the treatment of
Hyperthyroidism these patients need to be pre-treated with beta blockers glucocorticoids and iodine formulas surgery is usually done after five to seven days for watching this video you may like to watch other videos in this playlist please subscribe to our channel if you have not done yet you
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Thyroid Storm By Internal Medicine Made Easy
