The Journal of Emergency Medicine, Vol. -, No. -, pp.

1–7, 2016
Ó 2016 Elsevier Inc. All rights reserved.
0736-4679/$ - see front matter

http://dx.doi.org/10.1016/j.jemermed.2016.09.003

Clinical
Review

THYROID STORM IN A PATIENT WITH TRAUMA – A CHALLENGING DIAGNOSIS FOR

THE EMERGENCY PHYSICIAN: CASE REPORT AND LITERATURE REVIEW

Hsiang-I. Wang, MD,* Giou-Teng Yiang, MD, PHD,†‡ Chin-Wang Hsu, MD,§k Jen-Chun Wang, MD,{
Chien-Hsing Lee, MD, PHD,** and Yu-Long Chen, MD‡
*Department of Emergency Medicine, Taichung Armed Forces General Hospital, Taichung, Taiwan, †Department of Emergency Medicine,
School of Medicine, Tzu Chi University, Hualien, Taiwan, ‡Department of Emergency Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi
Medical Foundation, Taipei, Taiwan, §Department of Emergency Medicine, School of Medicine, College of Medicine, Taipei Medical
University, Taipei, Taiwan, kDepartment of Emergency and Critical Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan,
{Department of Emergency Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, and **Division of
Endocrinology and Metabolism, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei,
Taiwan
Reprint Address: Yu-Long Chen, MD, Department of Emergency Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation,
No.289, Jianguo Rd., Xindian Dist., New Taipei City 23142, Taiwan (ROC)

, Abstract—Background: Thyroid storm, an endocrine
emergency, remains a diagnostic and therapeutic challenge.
It is recognized to develop as a result of several factors,
including infection, surgery, acute illness, and rarely, trauma.
Recognition of thyroid storm in a trauma patient is difficult
because the emergency physician usually focuses on manag-
ing more obvious injuries. Objective of the Review: We pre-
sent a case of trauma-related thyroid storm and review the
previous literature on posttraumatic thyroid storm to delin-
eate risk factors of the disease. The case occurred in a
32-year-old man after a motorcycle accident. Discussion:
Careful investigation of patient history and risk factors of
trauma-related thyroid storms and utilization of the scoring
system may facilitate early diagnosis. Traumatically induced
thyroid storm usually responds to medical treatment devel-
oped for hyperthyroidism. Surgical intervention may be
needed for patients who failed medical treatment or those
with direct thyroid gland injuries. The outcome is usually
fair under appropriate management. Conclusion: We pre-
sent a case of trauma-related thyroid storm to illustrate the
diagnostic and therapeutic approach with a summary of
the previous literature. Emergency physicians should be
aware of the clinical presentation and risk factors of patients
with trauma-related thyroid storm to reduce the rate of
misdiagnosis and prevent catastrophic outcomes. Ó 2016
Elsevier Inc. All rights reserved.
, Keywords—thyroid storm; trauma; emergency
physician; risk factors; hyperthyroidism
INTRODUCTION
Thyroid storm, also known as thyroid crisis, is a rare
complication of thyrotoxicosis. Despite early diagnosis,
the overall mortality rate remains high at 10–30%. Four
main features characterize the clinical scenario: altered
mental status, hyperpyrexia, tachycardia, and gastrointes-
tinal dysfunction. Thyroid storm is typically precipitated
by several concomitant events such as infection, iodine-
containing contrast agent use, medication, pregnancy,
surgery, and acute illness. Trauma is a rare precipitating
factor (1).
Recognition of thyroid storm in a trauma patient is a
difficult task because the emergency physician usually fo-
cuses on managing more obvious injuries. The manifesta-
tions of thyroid storm, such as tachycardia or altered

RECEIVED: 18 April 2016; FINAL SUBMISSION RECEIVED: 27 July 2016;

ACCEPTED: 5 September 2016

1
2 H.-I. Wang et al.
consciousness, could be considered trauma-related. Careful
investigation of patient history and alertness to risk factors of
trauma-related thyroid storms may reduce the rate of misdi-
agnosis and prevent catastrophic outcomes.
In this study, we report a case of thyroid storm occur-
ring after a motorcycle accident and the issues associated
with its care, which occurred due to negligence in the
awareness of the trauma-thyroid storm relationship. We
also conducted a brief review of the literature focused
on posttraumatic thyroid storm to delineate the risk
factors.
CASE REPORT
A 32-year-old male motorcyclist, who used a helmet, pre-
sented to the emergency department after a road traffic
accident. On arrival 30 min after the accident, the patient
experienced severe agitation and diaphoresis. During the
primary survey, he was found to have dyspnea, a respira-
tory rate of 35 breaths/min, a heart rate of 155 beats/min,
and blood pressure of 138/94 mm Hg. The patient’s Glas-
gow Coma Scale scores were as follows: eye, 4; verbal, 2;
and motor, 4. His pupils were normal in size, equal, and
reactive to light. The injuries noted were multiple abra-
sions over his face and all four limbs, and a deformity
of the right lower limb. Radiographs detected closed frac-
tures of the right distal tibia and fibula. An additional 1 L
of crystalloid fluid was administered intravenously,
without a response. Given the impression of traumatic
hemorrhage, whole-body computed tomography was per-
formed, but it revealed no abnormalities of the head, cer-
vical spine, chest, or abdomen. When the patient returned
from Radiology to the resuscitation room, he became
increasingly agitated and exhibited tachypnea and tachy-
cardia, eventually reaching a heart rate of 178 beats/min,
blood pressure of 181/81 mm Hg, and tympanic temper-
ature of 38.4 C. Due to his agitation and severe tachyp-
nea, the patient was intubated with an endotracheal tube
for airway protection. A chest radiograph, taken after
intubation, revealed prominent hilar vessels and
butterfly-like central pulmonary opacities bilaterally,
consistent with pulmonary edema.
After a series of examinations and clinical manage-
ment, hypovolemic shock was excluded. Further ques-
tioning of his family revealed that the patient had been
diagnosed with thyrotoxicosis during a physical examina-
tion 1 year previously, but the patient denied using any
medication or attending follow-up. Several weeks prior,
he began to complain about mild diarrhea, palpitations,
easy agitation, and heat intolerance. Thyroid storm was
strongly suspected, and an endocrinologist was consulted
immediately. Ultrasonography revealed a diffuse goiter
with increasing vascularity but no hematoma (Figure 1).
Thyroid storm was diagnosed using the Burch and
Wartofsky score (Table 1): the patient had a score of 85
(temperature = 15, delirium = 20, diarrhea = 10, tachy-
cardia = 25, pulmonary edema = 15) (3). The patient
was admitted to the surgical intensive care unit, and treat-
ment was instituted according to the guidelines of the
American Thyroid Association.
Initial thyroid function tests revealed the following
data (normal values in parenthesis): free thyroxine (T4)
level of 8.56 ng/dL (0.8–2 ng/dL), thyroid-stimulating
hormone (TSH) level of < 0.03 mIU/mL (0.25–5.0 mIU/
mL), and total triiodothyronine (T3) level of 491.39 ng/
dL (100–190 ng/dL). After treatment with propylthioura-
cil, propranolol, hydrocortisone, and compound iodine
solution, the patient’s clinical status improved gradually.
On day 11, he was successfully weaned from the venti-
lator and transferred to the general ward. The patient
was discharged with neurologic sequelae, which required
neuro-rehabilitation.
DISCUSSION
Thyroid Storm and Trauma Overview
Thyroid storm, which occurs in approximately 1–10% of
inpatients with thyrotoxicosis, has been associated with
diagnostic and therapeutic challenges in clinical practice
since it was first characterized in 1926. It occurs more
commonly in women and among patients with Graves’ dis-
ease (4–6). Although the exact pathogenesis of thyroid
storm is not definitive, numerous precipitating factors,
namely infection, major trauma, surgery, parturition,
diabetic ketoacidosis, vascular accidents, noncompliance
with thyroid medication, iodine exposure from
radiocontrast dyes, amiodarone exposure, and emotional
stress, have been identified (1). Trauma is a rare cause
that has previously been reported in the literature. In a
recent nationwide survey of Japanese hospitals, trauma ac-
counted for 3.9% of cases of thyroid storm (7). However,
the symptoms of thyroid storm, which include altered con-
sciousness, tachycardia, and hypertension, may puzzle cli-
nicians when patients present with trauma. A delay in the
diagnosis of thyroid storm is potentially catastrophic, as
even early-diagnosed thyroid storm has an associated mor-
tality rate of 10–30% (4). We conducted a brief review of
the available literature, discussing the etiology, clinical
presentation, diagnosis, treatment, and outcome of patients
with posttraumatic thyroid storm.
After a brief review of the literature, we found 22 arti-
cles reporting cases of posttraumatic thyroid storm,
which was first described by Jacobs in 1979 (5,8–28).
For one article written in German, we used only the
data reported in the abstract (12). Considering that
some articles reported more than one case, and including
the present patient, we analyzed information on 25
Thyroid Storm in a Patient with Trauma
Figure 1. Diffuse goiter and enlargement of the thyroid gland (including the thyroid isthmus [narrow arrow], with increased
vascularity [wide arrow]).
patients. The clinical characteristics of the reviewed cases
are shown in Table 2 (29).
Etiology of Trauma-Related Thyroid Storm
The reviewed patients ranged in age from 15 to 74 years,
with a median age of 32 years. Most of the patients were
women (10 men [40%]; 15 women [60%]). Among these
patients with posttraumatic thyroid storm, 47.8% had a
history of hyperthyroidism with or without treatment. Af-
ter excluding patients with direct thyroid trauma, 62.5%
of patients with posttraumatic thyroid storm had a history
of hyperthyroidism. This suggests that patients with hy-
perthyroidism may be at great risk of developing thyroid
storm after trauma (18). The median Injury Severity
Score was 9 (range, 1–33), consistent with a moderate
severity of trauma (29). The lowest Injury Severity Score
was 1, indicating that even mild trauma can precipitate
thyroid storm, and the development of thyroid storms
seems to be unrelated to the severity of trauma. Concern-
ing the location of trauma, 15 (60%) patients had injuries
involving the head and neck, and over half of the patients
(53.3%) experienced direct injury to the thyroid gland.
Thyroid storm after blunt thyroid gland injury may be
3
caused by thyroid hormone release from the ruptured
acini. The other locations of trauma were the extremities
(n = 9, 36%), abdomen (n = 4, 16%), chest (n = 2, 8%),
and sites of burn injury (n = 1, 4%). Excluding direct
injury to the thyroid gland, posttraumatic thyroid storm
can occur even when the location of injury was remote
to the thyroid gland. The causative mechanism remains
unknown, but emotional stress induced by pain or anxiety
after traumatic episodes may play a role in such patients,
as it is regarded as a precipitant of thyroid storm.
Clinical Presentation of Trauma-Related Thyroid Storm
The clinical symptoms reported in the reviewed literature
are shown in Table 3. The most common symptoms of pa-
tients with posttraumatic thyroid storm were tachycardia
(96%), followed by fever (80%) and altered conscious-
ness (52%). A patient with thyroid storm will display se-
vere overstated signs and symptoms of hyperthyroidism,
including fever, central nervous systematic (CNS) symp-
toms, gastrointestinal and hepatic dysfunction, acute
renal failure, dysrhythmia, and other cardiovascular com-
plications. CNS symptoms are always observed, and they
range from agitation to delirium, confusion, numbness,
4 H.-I. Wang et al.
Table 1. Diagnostic Criteria for Thyroid Storm
Thermoregulatory Dysfunction: Temperature,  C Score
37.2–37.7 5 99–109
37.8–38.2 10
38.3–38.8 15
38.9–39.4 20
39.4–39.9 25
>40.0 30
Central Nervous System Dysfunction
Absent 0 Absent
Mild: Agitation 10
Moderate: Delirium, Psychosis, Extreme lethargy 20
Severe: seizure, coma 30
Gastrointestinal-Hepatic Dysfunction
Absent 0 Absent
Moderate: diarrhea, nausea/vomiting, abdominal pain 10
Severe: unexplained jaundice 20
Precipitant History
Absent 0
Present 10
A score of 45 or greater is highly suggestive of thyroid storm, a score of 25–44 supports the diagnosis of thyroid storm, and a score of <25 is
unlikely to denote thyroid storm.
Adapted from Burch and Wartofsky (2).
and even coma (7). Gastrointestinal symptoms include
nausea, vomiting, and severe diarrhea. Cardiac manifes-
tation may include palpitations, tachycardia, dyspnea
on exertion, widened pulse pressure, cardiac ischemia,
and atrial fibrillation, and the symptoms can progress to
congestive heart failure and cardiovascular collapse,
which may lead to shock (1). The largest single case se-
ries of thyroid storm to date comes from Japanese hospi-
tals that enrolled 356 patients from 2004 to 2008, and this
study provided valuable epidemiological and clinical
data. Tachycardia with a heart rate of higher than 130
beats/min was found in 73% of the patients, followed
by gastrointestinal manifestations (68%), CNS symptoms
(67%), fever (42%), and heart failure (39%) (7).
Emotional stress or hypovolemic shock after trauma
may contribute to the substantially higher incidence of
tachycardia (96% vs. 73%) in patients with posttraumatic
thyroid storm. This difference in the incidence of tachy-
cardia may be a compounding issue that allows clinical
physicians to overlook underlying medical emergency
conditions. Hence, if tachycardia tends to be out of pro-
portion to the underlying traumatic condition, thyroid
storm should be considered in the differential diagnosis.
Diagnostic Considerations
The diagnosis of thyroid storm depends on clinical find-
ings. In 1993, a landmark article by Burch and Wartofsky
created a thyroid storm scoring system. Each of the
different signs and symptoms was given a numerical
score (Table 1) (2). A score of 45 or greater is highly sug-
gestive of thyroid storm, a score of 25–44 is suggestive of
Cardiovascular Dysfunction:
Heart Rate, Beats/Min Score
5
110–119 10
120–129 15
130–139 20
$140 25
Cardiovascular Dysfunction: Heart Failure
0
Mild: Pedal edema 5
Moderate: Bibasilar rales 10
Severe: pulmonary edema 15
Cardiovascular Dysfunction: Atrial Fibrillation
0
Present 10
impending storm, and a score of < 25 is unlikely to denote
thyroid storm. Among the patients with posttraumatic
thyroid storm, the median score was 55 (range 25–85),
which is highly suggestive of thyroid storm, and even
the lowest score of 25 was suggestive of impending thy-
roid storm. Although the scoring system is not extremely
specific, its application in patients with posttraumatic
thyroid storm seems to be helpful in making a diagnosis
and providing further management.
Examination of thyroid function in patients with post-
traumatic thyroid storm revealed indicators of hyperthy-
roidism, which included low TSH (100%) and increased
T4 (95.7%) and T3 (80.9%) levels. As mentioned previ-
ously, the diagnosis of thyroid storm is mainly based on
a patient’s past history and clinical presentation. No defin-
itive serum T3 or T4 cutoff differentiates uncomplicated
thyrotoxicosis from thyroid storm, but a complete evalua-
tion of TSH, free T4, and T3 levels may facilitate confir-
mation of the diagnosis. Additionally, these laboratory
results can correlate the diagnosis with the associated clin-
ical symptoms and allow for the monitoring of treatment
outcomes.
Treatment of Trauma-Related Thyroid Storm
The therapeutic options employed in the reviewed cases
to treat posttraumatic thyroid storm are shown in
Table 2. After excluding one case for which treatment
was not described and one case in which only supportive
treatment was administered due to hypovolemic shock,
the remaining 95.8% of patients with posttraumatic thy-
roid storm received targeted medical treatment (22,23).
Thyroid Storm in a Patient with Trauma 5

Table 2. Clinical Characteristics of Patients with of thyroid storm has three objectives: inhibiting the synthe-
Posttraumatic Thyroid Storm
sis and release of thyroid hormone, inhibiting the periph-
Patients eral effects of thyroid hormone, and increasing thyroid
hormone clearance (1).
Median age, y 32 (15–74) Thioamides, which stop new thyroid hormone produc-
Sex, female 60%
History of hyperthyroidism 47.8% tion, include thiouracils (6-propyl-2-thiouracil) and imid-
Median ISS* 9 (1–33) azoles (methimazole and carbimazole), and they are most
Location of trauma commonly used as first-line treatments for thyroid storm.
Head and neck 60%
Extremity 36% The administration of iodine can block thyroid hor-
Abdomen 16% mone release (2). Lugol’s solution and potassium iodide
Chest 8% are drugs with proven efficacy in reducing thyroid hor-
Burn 4%
Median diagnostic score† 55 (25–85) mone release. Lithium may also be considered as a
Thyroid function test second-line agent to decrease thyroid hormone release
Low TSH 100% from the gland and reduce iodination of tyrosine residues.
High T3 80.9%
High T4 95.7% However, the mechanism is not well known, and the sub-
Medical treatment 95.8% sequent toxicity is complicated.
Thioamides 95% b-blockers, corticosteroids, and digoxin are agents that
Beta-blocker 90%
Corticosteroid 40% block the peripheral effects of thyroid hormone. b-blockers
Iodine 30% play an important role in the treatment of both uncompli-
Digoxin 20% cated and complicated hyperthyroidism. Propranolol is
Surgical intervention 13%
Outcome the most commonly used b-blocker due to its nonselective
Fair 84% b-adrenergic antagonism, and because it has the advan-
Neurological sequelae 12% tages of intravenous administration and the ability to
Death 4%
reduce the conversion of T4 to T3. However, side effects
TSH = thyroid-stimulating hormone; T3 = triiodothyronine; of b-blockers may result in difficult situations when used
T4 = thyroxine. in trauma patients experiencing shock. When clinical man-
* ISS = Injury Severity Score (29).
† Calculated using the symptoms described in the article accord- ifestations of thyroid storm persist and a hyper-dynamic
ing to the diagnostic criteria for thyroid storm. state is demonstrated, treatment with b-blockers should
be used cautiously and in conjunction with close clinical
and intensive hemodynamic monitoring. Corticosteroids
This treatment focused on the synthesis and release of
may be useful in preventing adrenal insufficiency and
thyroid hormone as well as reducing the effects of
decreasing the peripheral conversion of T4 to T3. The
peripheral hormone to avoid end-organ damage. The
use of digoxin was noted in the reviewed cases reported
most frequently chosen treatments were thioamides
(95%), b-blockers such as propranolol or esmolol prior to 1995; its antidysrhythmic effect may help to
(90%), corticosteroids (40%), iodine (30%), and digoxin manage tachydysrhythmia in patients with thyroid storm
(20%). Surgical intervention with thyroidectomy was (5,8,11). However, the narrow therapeutic range of
digoxin and increased benefit of b-blockers may limit the
performed in 3 patients (13%), all of whom had a direct
use of the drug in patients with thyroid storm.
thyroid gland injury (20,21).
Surgical management for thyroid storm is usually per-
Due to its high mortality rate, treatment should start as
formed via subtotal or near-total thyroidectomy (2). All pa-
soon as thyroid storm is suspected. These critical patients
tients who fail medical therapy should undergo therapeutic
are usually admitted to intensive care units for close moni-
toring and aggressive treatment. The medical management plasma exchange or early surgical intervention (within 12–
72 h). Among patients with posttraumatic thyroid storm,
almost all patients were treated medically, and even among
Table 3. Summary of the Symptoms of Posttraumatic the cases of direct injury to the thyroid gland, only 3 pa-
Thyroid Storm (N = 25) tients who had traumatic thyroid gland hemorrhage were
treated surgically via debridement of the hematoma or
Symptoms n (%)
crushed thyroid tissue and lobectomy or thyroidectomy.
Tachycardia 24 (96)
Fever 20 (80) Outcome of Trauma-Related Thyroid Storm
Altered level of consciousness 13 (52)
Gastrointestinal discomfort 6 (24)
Heart failure 6 (24) Treatment outcome was reported for 25 cases. Twenty-one
Atrial fibrillation 4 (16) patients (84%) had complete resolution of symptoms, 3
Multiple organ dysfunction 2 (8)
(12%) experienced neurological sequelae, and one (4%)
6 H.-I. Wang et al.
died due to thyroid cancer with multiple vertebral metasta-
ses and quadriplegia-complicated respiratory failure (15).
The outcomes of thyroid storm mainly depend on immedi-
ate and appropriate treatment, and the overall mortality rate
is approximately 10–30% (4,7). In a survey of Japanese
patients with thyroid storm, the leading causes of death
included multiple organ failure (24%) and congestive
heart failure (21%) (7). Furthermore, various morbidities,
such as brain injury, disused muscle atrophy, intracranial
vascular disease, impaired renal function, and subsequent
psychosis, may require long-term care (1). Among patients
with posttraumatic thyroid storm, the outcome seems to be
better than that of thyroid storm of other etiologies. How-
ever, the mechanism of interaction is not clear, and further
well-defined epidemiological studies may be required to
verify the difference between posttraumatic and nontrau-
matic thyroid storm.
CONCLUSIONS
Trauma is a rare cause of thyroid storm, and the diagnosis
of thyroid storm may be difficult due to the overlap of
many clinical findings between thyrotoxicosis (tachy-
cardia, altered mental status, abdominal pain) and hypo-
volemic trauma. The emergency physician should always
consider a diagnosis of thyroid storm if the patient has a
history of hyperthyroidism and trauma of moderate
severity. The scoring system and laboratory data could
help to diagnose and monitor the outcome of treatment.
Traumatically induced thyroid storm should respond to
medical treatment for hyperthyroidism. Surgical inter-
vention is indicated for patients who fail medical treat-
ment or those with direct thyroid gland injury. The
outcome is usually fair given appropriate management.
Acknowledgment—We acknowledged Dr. Shih-Hung Tsai for
English revision and idea organization.
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Thyroid Storm in a Patient with Trauma 7

ARTICLE SUMMARY
1. Why is this topic important?
Trauma-related thyroid storm, although uncommon,
can result in catastrophic outcomes such as mortality or
severe neurologic sequelae. The presentation of thyroid
storm in a trauma patient requires rapid diagnosis and
appropriate management by the emergency physician
for optimal results.
2. What does this review attempt to show?
Recognition of thyroid storm in a trauma patient is a
difficult task because emergency physicians usually focus
on managing more obvious injuries and overlook the med-
ical cause of abnormal presentations, such as altered con-
sciousness and tachycardia. We presented a case of
thyroid storm after a motorcycle accident and reviewed
the previous literature on posttraumatic thyroid storm to
delineate the risk factors of the disease. Awareness of
the risk factors of trauma-related thyroid storm may
reduce the rate of misdiagnosis and prevent catastrophic
outcomes.
3. What are the key findings?
We have provided a comprehensive review of the clin-
ical presentations of, as well as the diagnostic and thera-
peutic approaches for, trauma-related thyroid storm.
Emergency physicians should be aware of patients with
a history of hyperthyroidism, trauma of moderate severity,
and head and neck injury. Careful investigation of the his-
tory and utilizing the scoring system may facilitate early
diagnosis. Traumatically induced thyroid storm usually
responds to medical treatment developed for hyperthy-
roidism. Surgical intervention may be needed for patients
who fail medical treatment or those with direct thyroid
gland injury. The outcome is usually fair, given appro-
priate management.
4. How is patient care impacted?
Thyroid storm is a rare complication of thyrotoxicosis,
and even with early diagnosis, the overall mortality rate
remains high. By approaching and framing the clinical
presentation and using the score system, emergency phy-
sicians can more accurately select diagnostic and thera-
peutic options for patients with trauma-related thyroid
storm to reduce the rate of misdiagnosis and prevent cata-
strophic outcomes.