Thyroid Storm

Objectives
1. Introduction to thyroid disease
2. To discuss the pathophysiology of hyperthyroidism
3. To define thyroid Storm
4. To differentiate between thyroid Storm and other diagnosis
5. How to deal with thyroid Storm in the emergency
department
Thyroid hormone functions include

• Regulate the rate at which calories are burned, affecting

weight loss or weight gain.
• Can slow down or speed up the heartbeat.
• Can raise or lower body temperature.
• Influence the rate at which food moves through the
digestive tract.
• Control the way muscles contract.
Introduction to
Thyroid disease
Thyroid disease can be divided into:

Hyperthyroidism Hypothyroidism
Pathophysiology of hyperthyroidism:
There are tow types of hyperthyroidism
either primary which is caused by excess production of thyroid hormones from the
thyroid gland.
Or secondary which is caused by excess production of TRH from the hypothalamus
or TSH form pituitary
Other causes of hyperthyroidism include iodine or amiodarone use , ingestion of
excessive thyroid hormone , and thyroid hormone production at ectopic sites
(ovarian teratoma)
Hyperthyroidism symptoms

SWEATING

-Sweating
-Weight loss
-Emotional liability
-Appetite increased
-Tremor/ tachycardia
-Intolerance of heat
-Nervousness
-Goiter and GI problems
(diarrhea)
 If the hyperthyroidism is not treated or
undetectable this will lead to a condition
called thyroid Storm or crisis.
Thyroid storm
Is a rare but severe and potentially life-threatening complication
of hyperthyroidism (overactivity of the thyroid gland).
It is characterized by a high fever (temperatures often above
40°C, fast and often irregular heart beat, elevated blood
pressure, vomiting, diarrhea, and agitation.
Precipitant of thyroid Storm include
• Infection
• Trauma
• Pulmonary embolism
• Surgery
• Iodine administration
• Diabetic ketoacidosis
• Withdrawal of thyroid medication
• Idiopathic causes (25%)
Signs and symptoms

Are related to enhanced sympathetic nervous system activity

and include Central nervous system disturbance
(confusion, delirium, coma)
Cardiovascular abnormalities (atrial fibrillation, congestive
heart failure) and stimulated gastrointestinal motility and
diarrhea
Diagnosis
A suppressed TSH and elevated free T4 and free T3 confirm the
diagnosis of primary hyperthyroidism.
In cases of secondary hyperthyroidism TSH, FT3, FT4 are all
elevated.

.
Differential diagnosis of thyroid Storm includes :

• Sepsis
• Causes of congestive heart failure
• Stroke
• Complications of diabetic
• Medication withdrawal
• Organophosphate overdose
Emergency department care
and disposition
Treatment of thyroid Storm can be divided
into three parts :

1. General supportive care.

2. Pharmacologic therapy.
3. Identification and treatment of precipitating events.
General supportive care include :

• Airway assessment
• Supplemental oxygen
• Intravenous fluid
• And cardiac monitoring
Pharmacological therapy divide into:
Local agents

• Propylthiouracil 600 mg / PO loading dose followed by 200

mg every 4h
Or
• Methimazole 40 mg / PO loading dose followed by 25 mg
every 4h

o Lugol's solution 8 drops PO every 6h

Or
o Potassium iodide 5 drops PO every 6 h
Or
o Iopanoic acid 1 gram IV every 8 h
Or
o Lithium carbonate 300 mg PO every 6 h
Systemic agents

• Propranolol 1 mg / IV every 15 min

Or
• Resepine 1 mg / IM test dose*

o Hydrocortisone 40 mg / IV every 8 h
Or
o Dexamethasone 2 mg / IV every 6 h
Identification and treatment of
precipitating events

• infection
• Trauma
• Surgery
• Etc..
Conclusion
There are many diseases related to thyroid but the most
important one which is life threatening is THYROID
STORM a rare but severe and potentially life-threatening
complication of hyperthyroidism (overactivity of the thyroid
gland).
References
o Tintinalli's emergency medicine
o Japan guidelines for management of thyroid Storm
Any question