Group 4 Thyroid Storm ALA

NORTHWESTERN UNIVERSITY
College of Allied Health Sciences

DEPARTMENT OF NURSING
Laoag City
Tel. No. (077)-670-8609 to 10 Fax (077) 771-3814
email: info@nwu.edu.ph website: www.nwu.edu.ph
ALTERNATIVE LEARNING ACTIVITIES
THYROID STORM
In partial fulfillment of the Course Requirements in Care of Clients with Life Threat.
Condition, Acutely Ill/Multi Organ Prob., High Acuity & Emergency Situation, Acute &
Chronic (NCM 118)
Presented by:
Agbayani, Lovely Joy
Agullana, Kayra Kevi Gwayne
Daleja, Joshua
Gonzales, Nina
Madalipay, Charisma Belle
Mamuad, Kimberly Aena
Rabaja, Ericka Joyce
Ranada, Ernellie
Soliva, Theresa
Tacderan, Jamaica
BSN IV B- Group 4
Presented to:
Glenn B. Lagdao, RN
Marie Genevieve C. Agodon, MAN
Aprile D. Rabbon, MAN
Clinical Instructors
First Semester A.Y. 2021-2022
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TABLE OF CONTENTS
I. CASE SCENARIO 3
II. INTRODUCTION 6
III. PATHOPYSIOLOGY 8
IV. DISCHARGE PLANNING 10
V. RELATED NURSING THEORY 12
VI. REVIEW OF RELATED LITERATURE/STUDIES 14
VII. REFERENCES 24
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I. CASE SCENARIO
Patient X, female presents to the emergency room per wheelchair

accompanied by significant other with complaints of intractable nausea,
vomiting and anxiety for 2 days.
Mrs. X, 38 years old, married, is from Sampaloc, Manila; with a weight is
48 kgs and height 157 cm.
Assessments:
Subjective: verbalized “I feel very weak, as I vomit like every now and
then.”
Objective:
➢ BT = 39.5 C
➢ RR = 24 breaths per min
➢ HR= 146 beats per min
➢ Glasgow coma scale = 14
➢ BP = 140/55 mmHg
Also,
➢ Patient was agitated and acutely anxious but still awake and a bit
confused.
➢ Diaphoretic and flushed with no jugular venous distention, no
peripheral edema.
➢ Clear breath sounds on lung examination.
Her past history showed no diagnosis of hypertension, diabetes mellitus or

thyroid disease however it was noted in the family history that her mother
received treatment for Grave’s disease. The patient had experienced 7 kg weight
loss, intermittent palpitation and hand tremors for the past 4 months after giving
birth to her youngest child. According to the patient’s significant
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other, they have no recollection or knowledge about any chronic illness nor
injuries that she had. She delivered her youngest child via C-section in Ospital
ng Maynila and had undergone bilateral tubal ligation. She has no reported
allergies however she admitted having been engaged with alcohol abuse when
she lost her parents a couple of years ago. She stated that she had no time for
any form of exercise because of her stressful work schedule, she works about
10 – 12 hours a day from Monday to Saturday as a supervisor at a food
manufacturing company in Bulacan. She would only get about 4-6 hours of
sleep most of the time and during her free time, she spends it in reading books
and has been into seafoods lately. For patients’ medication history, it is stated
there that she would normally rely on Ibuprofen or Mefenamic acid for pain
relief and sometimes Aspirin.
Diagnostic tests ordered were complete blood count as part of the evaluation
to look for high levels of thyroid hormones in the blood. Requested for thyroid
ultrasound to check if thyroid function test is normal. He also ordered Thyroid-
stimulating hormone (TSH) test to check level of TSH and also to provide
information on what is happening in the body.
Laboratory/diagnostic findings:
➢ CBC: basic metabolic panel and lipase were all normal

➢ Thyroid function test results showed TSH: 0.08 µIU/mL; Free thyroxine
(FT4): 5.0 ng/dL (normal range = 0.9-2.3 ng/dL); Free triiodothyronine
(FT3) = 2900 pg/dL (normal range = 249- 405)
➢ Thyroid peroxidase and thyroid stimulating immunoglobulin levelswere
within normal range.
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➢ A thyroid ultrasound revealed diffuse heterogeneity consistent with

non-specific thyroiditis.
➢ Electrocardiography showed sinus tachycardia.
Medical Management
Physician ordered the following: 1L PNSS to be infused at 8⁰ at31gtts/min,
Amlodipine 10 mg P.O. Stat and administer Oxygen at 3 lpm PRN via nasal
cannula, Methimazole 40 mg once a day P.O., Propranolol 20 mg TID per Orem
and patient was placed on a low-iodine diet.
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II. INTRODUCTION
The objective of this activity is to provide information about thyroid storm,

how it usually begins, what can cause the disease or who is at risk of having it,
ways on how one can prevent from acquiring it is also included as well as the
management of the disease.
Thyroid storm (thyrotoxic crisis) is a form of severe hyperthyroidism,

usually of abrupt onset. Thyroid storm is characterized by high fever >38.5°C,
extreme tachycardia (>130 bpm), exaggerated symptoms of hyperthyroidism
with disturbances of a major system—for example, gastrointestinal (weight
loss, diarrhea, abdominal pain) or cardiovascular (edema, chest pain, dyspnea,
palpitations), and altered neurologic or mental state, which frequently appears
as delirium psychosis, somnolence, or coma. Life-threatening thyroid storm is
usually precipitated by stress, such as injury, infection, thyroid and non- thyroid
surgery, tooth extraction, insulin reaction, diabetic ketoacidosis, pregnancy,
digitalis intoxication, abrupt withdrawal of antithyroid medications, extreme
emotional stress, or vigorous palpation of the thyroid. These factors can
precipitate thyroid storm in the partially controlled or completely untreated
patient with hyperthyroidism. Current methods of diagnosis and treatment for
hyperthyroidism have greatly decreased the incidence of thyroid storm, making
it uncommon today.
Statistical Data
Thyroid storm accounts for about 1% to 2% of admissions for

hyperthyroidism. As per the United States survey, the incidence of storm ranged
from 0.57 t0 0.76 cases per 100,000 per year in the normal population, and 4.8
to 5.6 cases/100,000 per year in hospitalized patients. As per the
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Japanese National Survey, the incidence of thyroid storm was 0.2 per 100,000
population per year, about 0.22% of all thyrotoxicosis patients and 5.4% of
hospitalized thyrotoxicosis patients. The average age of people with thyroid
storm was 42 to 43 years, which was similar to people with thyrotoxicosis
without thyroid storm. The male to female ratio for the incidence of thyroid
storm was about 1:3, similar to thyrotoxicosis without storm group.
The related implications of this activity in the nursing education is that this
can serve as a guide to students and clinical instructors in expanding their
awareness of the said disease and can help in improving effective ways to
deliver quality health care to patients as well as in the development of providing
quality education in the nursing profession. In the nursing profession, this will
aid the members of the health care system in determining best nursing practices,
pave new treatment/management, providing better nursing interventions which
will improve patient care who received a diagnosis of thyroid storm. As to the
nursing research, this will be a useful reference for the researchers who would
plan to make any related activity precisely with the standard underlying the
nursing program.
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III. PATHOPHYSIOLOGY
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IV. DISCHARGE PLANNING
Discharge planning is the process of transitioning a patient from one level

of care to the next. Ideally, discharge plans are individualized instructions
provided to the patient as they move from the hospital to home or instructions
provided to subsequent healthcare providers as they move to a longer-term care
facility. These are the plans to improve a patient’s quality of life by ensuring
continuity of care.
GOAL/OBJECTIVES DISCHARGE INSTRUCTION/

INTERVENTIONS
The goal of Medication is: • Advice the patient to continue

prescribed home medications (e.g.,
• To promote and maintain health. Tapazole)
• To relieve pain and sufferings Rationale: to ensure optimum
caused by disease. recovery.
The goal of the Diet is: • Encourage the patient eat green
leafy vegetables.
• To maintain good nutritional status. Rationale: Including green leafy
• To provide rest to the body. vegetables is necessary to meet
calcium requirement. In a condition
such as hyperthyroidism the
antioxidant levels in tissues go
down. Fruits which are a good
source of vitamin C, which is a
powerful antioxidant, when
included in the diet would be
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beneficial for people with
hyperthyroidism.
• Avoid eating excessive amounts of

iodine-rich foods (e.g., seafoods
anddairy products such as milk,
yogurt and cheese).
Rationale: The effect of iodine
supplements can vary by person,
causing the thyroid to produceeither
too much or too little
hormone.
The goal of health teaching is: • Encourage the patient to restrict
activity like strenuous activities (e.g.
• To improve norms of good health. running, jogging, race walking and
• To give preventive measures aerobic dancing) and rest in bed as
against the disease. much as possible.
• To reduce disabilities and deaths. Rationale: to help counteract
effects of increased metabolism.
• Provide comfort measures like

massage therapy.
Rationale: may decrease nervous
energy, promoting relaxation.
The goal of Follow-Up Care is:
• Emphasize the importance of follow-
up checkup.
• To see how the patient is doing. Rationale: This is vital for
• To check on patient’s progress. ensuring the patient moving
• To ensure there aren’t forward with the prescribed
complications. treatment plan.
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V. RELATED NURSING THEORY
The primary purpose of theory in the profession of nursing is to improve

practice by positively influence the health and quality of life of patients. Nursing
theories are also developed to define and describe nursing care, guide nursing
practice, and provide a basis for clinical decision making. The accomplishments
of nursing in the past led to the recognition of nursing in academic discipline,
research, and profession. The three circles are: the core, the care, and the cure
also known as the Three Cs of Lydia Hall; this theory contains three independent
but interconnected circles. A participation in care, core and cure aspects of
patient care, where care is the sole function of nurses, whereas the core and cure
are shared with other members of the health team. The patient may first be
overwhelmed at the thought of managing the disease, fear of being alone and
fear of the disease in itself patient was diagnosed with Thyroid Storm. Thyroid
storm also referred to as thyrotoxic crisis, is an acute, life- threatening,
hypermetabolic state induced by excessive release of thyroid hormones in
individuals with thyrotoxicosis. The nurse’s role includes educating patients and
helping a patient meet any needs she is unable to meet alone. Care circle defines
providing bodily care for the patient and helping the patient complete basic daily
functions such as eating, bathing, elimination, and dressing. The core circle,
according to Hall’s theory, is the patient receiving nursing care has goals set by
herself rather than by any other person and behaves according to their feelings
and values. This area emphasizes thepatient’s social, emotional, spiritual, and
intellectual needs concerning family, institution, community, and the world.
This can help the patient verballyexpress feelings regarding the disease process
and its effects by using the
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reflective technique. The cure which involves the administration of

medications, treatments and also nursing care for the patients’ symptoms.
Hall believed that patient outcomes are improved by direct care as given
by the professional nurse. In short, these are the interventions or actions geared
toward treating the patient for whatever illness or disease he or she is suffering
from. During this aspect of nursing care, the nurse is an active advocate of the
patient.
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VI. REVIEW OF RELATED LITERATURE/STUDIES
RELATED LITERATURE
Thyroid Storm Presenting as psychosis
According to Bindu Nayak et. al. (2006), Thyroid storm is a rare, but life-
threatening complication of hyperthyroidism. The most common etiology of
thyroid storm is Graves’ disease, as was seen in our patient, followed by other
causes of hyperthyroidism such as a solitary toxic adenoma or toxic
multinodular goiter. Rare causes of hyperthyroidism such as hypersecretory
thyroid carcinoma, struma ovarii, thyrotropin-secreting pituitary tumor, and
administration of iodine via radiocontrast dye or amiodarone are also among
reported etiologies. A precipitating event is usually identified that results in
transition from hyperthyroid state to thyroid storm. In the past, thyroid surgery
during uncontrolled hyperthyroidism was the most common reason for thyroid
storm; presently, infection is the most common precipitant. Other precipitating
factors include myocardial infarction, pulmonary thromboembolism,
parturition, surgery, trauma, diabetic ketoacidosis, withdrawal of antithyroid
drugs, and administration of iodine (intravenous radiocontrast dye or
amiodarone). Four main clinical features of thyroid storm include fever,
tachycardia, gastrointestinal symptoms, and CNS involvement. CNS
manifestations of thyrotoxicosis fall in a vast spectrum ranging from emotional
lability, anxiety, agitation, confusion, delirium, paranoia, mania, frank
psychosis, seizures, and even coma. The association between psychosis and
thyrotoxicosis has been suggested in a review of 18 patients with acute
psychosis and newly diagnosed thyrotoxicosis. In a recent case series of 28
patients with thyroid storm, 8 of them were seen to have neuropsychiatric
involvement. Although there are individual case reports of Graves’ disease
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and thyrotoxicosis presenting as psychosis, there are only a handful of cases

reported in the literature where psychosis was the presenting feature of thyroid
storm. In addition to the unusual manifestation of thyroid storm, our patient’s
resistance to the conventional medical management with worsening psychosis
and hyperthyroidism added to the challenge of management. There are very few
studies in literature describing cases and etiologies of resistant thyrotoxicosis.
Refractory cases of thyroid storm have been reported either as results of
amiodarone-induced thyrotoxicosis or Grave’s disease.
Coma in Thyroid Storm
According to Lynn A Burmeister et. al. (2019), The most common systemic
findings associated with the TS-related coma state were tachycardia (88%) and
fever (83%). Cardiovascular abnormalities, including heart failure,
hypertension, and atrial fibrillation, were the second- most common events,
followed by liver or kidney dysfunction. Temperature ≥101°F was reportedin
45 cases (69%), and temperature ≥104°F was seen in 18 cases. Heart rate
>140 beats per minute was reported in 39 cases (60%). Comorbidities that can
also affect the level of consciousness were present in some cases, including
hypotension, hypoglycemia, or hepatic failure. Systemic findings associated
with TS-related coma were not different between patients reported in case
reports and those reported in case series. The most common systemic findings
associated with the TS-related coma state were tachycardia (88%) and fever
(83%). Cardiovascular abnormalities, including heart failure, hypertension,and
atrial fibrillation, were the second-most common events, followed by liver or
kidney dysfunction. Temperature ≥101°F was reported in 45 cases (69%), and
temperature ≥104°F was seen in 18 cases. Heart rate >140 beats per minute
was reported in 39 cases (60%).
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Comorbidities that can also affect the level of consciousness were present in
some cases, including hypotension, hypoglycemia, or hepatic failure.Systemic
findings associated with TS-related coma were not different between patients
reported in case reports and those reported in case series.
Thyroid storm with Multiorgan Failure treated with plasmapheresis
According to Ann Miller and Kristi Silver (2019), Plasmapheresis is an

extracorporeal blood purification technique that helps remove larger molecular
weight substances from blood. Plasmapheresis is a general term that refers to
removing plasma from blood. TPE is a type of plasmapheresis that involves
removal of patient plasma and replacing it with something else (donor plasma,
colloid, or crystalloid). TPE is most often used to treat conditions, where a
pathogenic substance or component is in the blood and needs to be rapidly
removed. The necessary tools for TPE include vascular access, either using
large-bore needles in the limb veins or an implanted catheter in the large veins
of the neck, chest, or groin, and a plasmapheresis machine. The machine
separates the patient’s plasma from the rest of the blood components and
exchanges plasma with a replacement fluid. TPE is effective for treatment of
thyroid storm as thyroid hormone is almost entirely bound to plasma proteins
(99.97% of total serum T4 and 99.7% of total serum T3). The three main plasma
proteins that bind T4 and T3 are thyroxine binding globulin (TBG),
transthyretin, and albumin. TBG binds 75% of T4 and T3. Transthyretin binds
20% of T4 and <5% of T3. Albumin binds 5% of T4 and 20% of T3. TBG and
transthyretin are relatively similar in size, 54 kDa and 55 kDa, respectively.
Albumin is larger with a molecular mass of 66.5 kDa. Because of the size of
thyroid binding proteins, conventional dialysis cannot remove these proteins
from blood. In contrast, TPE removes larger proteins, and thus can
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be used to reduced circulating thyroid hormone and treat refractory thyroid

storm. TPE can also remove TSH receptor autoantibody (also referred to as
thyroid stimulating immunoglobulin) and its removal has been predicted
mathematically to result in rapid lowering of the free thyroxine levels.
Thyroid storm triggered by strangulation in a patient with undiagnosed

graves’ disease
According to Marilyn A. Arosemena et. al. (2018), Thyroid storm is the life-
threatening end-organ manifestation of severe thyrotoxicosis. If left untreated,
thyroid storm may cause acute heart failure, multiorgan dysfunction, and death.
A high degree of suspicion is necessary to make the diagnosis and start
antithyroid medications to decrease mortality. Thyroid storm is generally seen
in patients with Graves’ disease but should also be suspected in patients with
fever, tachycardia, altered mental status, and risk factors including local trauma
to the neck, such as strangulation. Thyroid storm (accelerated hyperthyroidism)
is a rare, life-threatening syndrome characterized by end- organ compromise
most commonly occurring in patients with known history of Graves’ disease
but may also be the initial presentation of thyrotoxicosis. Less commonly,
thyroid storm may be precipitated by an acute event, such as surgery, infection,
diabetic ketoacidosis, or parturition.
RELATED STUDIES
Case series: Rare cases of thyroid storm in COVID-19 patients
In this study related to our topic, Nasrin Milani et. al. (2021) the patients
with COVID-19 can be asymptomatic or experience a variety of dangerous
conditions. New aspects of this multiorgan disease are recognized every day.
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This pandemic disease has been associated with numerous autoimmune

diseases, such as autoimmune thyroiditis. As evidenced by the SARS epidemic, a
considerable number of these patients experience abnormalities in thyroid
function due to virus damage to the thyroid gland and its follicular architecture.
In a study performed on subjects from more than 200 countries, COVID-19
patients were evaluated for thyroid disease. Out of 58 patients, overtthyrotoxicosis
was observed in 31 (53%) cases with thyroid during the COVID- 19 pandemic.
Moreover, it was found that there was a relationship between the levels of IL-6
and TSH, suggesting inflammation-induced damage that can exert negative
effects on thyroid. Therefore, it can be stated that thyrotoxicosis has negative
effects on outcomes. Furthermore, in a meta-analysis, it was indicated that people
with pre-existing thyroid disease were more likely to develop severe COVID-19
disease. Nevertheless, the limitations of the present study do not allow us to
generalize these findings.
Thyroid storm can be identified by different diagnostic criteria, such as
Burch-Wartofsky scores (BWSs) and Akamizu (Ak) criteria. The comparison
between the diagnosis and outcomes in patients with thyroid storm and
compensated thyrotoxic pointed out that patients with thyroid storm had more
prolonged stays in hospital and intensive care units, ventilation requirements, and
in-patient mortality, as compared to compensated thyrotoxic patients.The
reversible complications can be controlled by understanding the diagnostic criteria
of thyroid storm and factors contributing to mortality in these critically ill patients
who were infected with COVID-19. (Nasrin Milani et. al. 2021) Previous studies
conducted on SARS-CoV patients illustrated that in some cases, thyroid function
improved within 3–6 months, suggesting that survivors should be re-evaluated.
According to the results of the present study, it is suggested that thyroid function
tests be monitored during the acute and convalescence stages of COVID-19. In
case of any thyroid dysfunction, the possibility of replacement therapy should be
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considered as indicated. (Nasrin Milani et. al. 2021)
The Philippine Thyroid Diseases Study (PhilTiDeS 1): Prevalence of Thyroid

Disorders Among Adults in the Philippines
According to Jimeno et. al. (2012), The prevalence of thyroid dysfunction
in this Philippines survey is 8.53%, with the predominant problem being
subclinical hyperthyroidism at 5.33%. A study in southern Taiwan among the
elderly above 65 years old showed a prevalence rate of thyroid dysfunction of
6.8%. In another study looking at thyroid disease and dysfunction among adults
in Norway, the prevalence of previously diagnosed hyperthyroidism was 2.5%
in females and 0.6% in males, and the prevalence of hypothyroidism was 4.8%
in females and 0.9% in males. These values are quite different from what we
obtained in the Philippine population and may reflect differences in both the
genetic and physical environment. Worldwide, the prevalence of hyperthyroidism
in women is between 0.5 and 2%, and is ten times more common in women than
in men in iodine-replete communities. In the Whickham survey in the U.K., the
prevalence of undiagnosed hyperthyroidism was 4.7 per 1000 women.
Hyperthyroidism had been previously diagnosed and treated in 20 per 1000
women, rising to 27 per 1000 women when possible but unproven cases were
included, as compared with 1.6 to 2.3 per 1000 men, in whom no new cases were
found at the survey. The mean age at diagnosis was 48 years, the Philippine data
appears similar with 0.61% prevalence of true hyperthyroidism(6 per 1,000) with
mean age of 51 years.
Minor degrees of thyroid dysfunction that may seem inconsequential may
lead to dire consequences in vulnerable patients such as those with cardiovascular
disease and the elderly. Subclinical hyperthyroidism can lead to disturbances in
bone metabolism and cardiac function such as atrial fibrillation. Individuals on
levothyroxine with subclinical hyperthyroidism who were studied using Doppler
echocardiography and 24-hour Holter electrocardiogram
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monitoring showed increased 24 hour mean heart rate and

supraventricular arrhythmia, left ventricular mass index, higher rate of systolic
function and impairment of diastolic dysfunction. A low serum TSH concentration
is generally a sensitive marker of thyroid hormone excess and has been reported
in a large population-based study to be associated with a 3-fold higher risk of
developing atrial fibrillation (AF) in the subsequent decade. The cumulative
incidence of AF after 10 years among subjects with a low TSH concentration
(0.1 mU/liter) was 28%, compared with 11% in those with a normal TSH (p =
0.005). The presence of atrial fibrillation predisposes to embolic events which
may contribute to increased vascular mortality among patients with excess thyroid
hormones. Perhaps, the most deleterious effect of subclinical hyperthyroidism is
that it predicts future risk of development of overt hyperthyroidism. (Jimeno et.
al. 2012)
Subclinical hyperthyroidism appears to pose more problems for the elderly
and has been particularly well-studied in this population. It is associated with a
higher mortality rate in chronically-ill geriatric patients (62% versus 28%, p
<0.05) and poses a 2.2-fold risk in mortality from all causes and 3-fold risk of
cardiovascular death among those aged more than 60 years old after a single
measurement of low TSH. These studies support the recommendations on
screening for thyroid dysfunction and treatment of subclinical hyperthyroidism
among the elderly. Subclinical hypothyroidism has been associated with
dyslipidemia that can lead to cardiovascular disease. Detection and correction can
correct its consequences and improve health. Knowledge of this data should be
able to help our government policy makers, health insurance policy makers and
individual health practitioners to make the necessary steps to address the thyroid
dysfunction of our many. (Jimeno et. al. 2012)
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Cardiorespiratory Failure in Thyroid Storm: Case Report and Literature

Review
Research done by Qiang Nai et. al. (2018), thyroid disease is a common
illness affecting 9% to 15% of the adult. In adult population, thyroid disease
affects women more often than men. This gender difference can most likely be
attributed to the underlying autoimmune mechanism for the vast majority of
thyroid diseases, including Graves’ and Hashimoto’s disease. However, this sex
difference becomes less prominent with advancing ages, especially beyond the
age of 80. Both hyperthyroidism and hypothyroidism cause derangement in heart
and vasculature. It is well known that hyperthyroidism induces tachycardia,
enhances left ventricular systolic and diastolic function, and increases occurrence
of supraventricular tachyarrhythmia, such as atrial fibrillation. On the other hand,
hypothyroidism exerts largely opposite effects on cardiovascular system.
However, it is worth mentioning that hypothyroidism predisposes patients to
systemic hypertension and ventricular tachycardia.
Thyrotoxicosis refers to the clinical syndrome of hypermetabolism due to
excessive amount of circulating thyroid hormones. Thyrotoxicosis can result from
the destruction of thyroid follicles and thyrocytes as in thyroiditis, excessive
exogenous thyroid hormone intake, or hyperthyroidism that is defined as
inappropriate increase in the biosynthesis and secretion of thyroid hormones by
thyroid glands. Graves’ disease is the most common form of thyrotoxicosis.
Thyroid storm, also known as thyrotoxic crisis, is a rare acute hypermetabolic state
resulting from excessive release of thyroid hormones. It mostly occurs in
individuals with untreated or undertreated thyrotoxicosis. Thyroid storm can be
precipitated by trauma, surgery, or infection. Common symptoms and signs of
thyroid storm include hyperthermia, tachycardia, hypertension, nausea, vomiting,
tremulousness, agitation, and psychosis. Thyroid storm also can cause stupor or
coma. Congestive heart failure may occur and lead to hypotension and shock.
(Qiang Nai et. al. 2018)
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Thyroid storm is almost always fatal without proper treatment.

Cardiopulmonary failure is the most common cause of death in thyroid storm,
particularly in elderly patients. Fortunately, owing to the advance of diagnosis and
therapeutic strategies, the mortality of this disorder has dropped from nearly 100%
to 10%. However, since laboratory confirmation is often delayed, thyroid storm
must be diagnosed promptly on clinical grounds to allow expeditious provision of
life-saving treatment. Therefore, a high index of suspicion and the ability of early
diagnosis of impending thyroid storm is critical, which are in turn dependent on
a thorough knowledge of both the typical and atypical clinical features of this
illness. (Qiang Nai et. al. 2018)
Thyroid Storm Due to Functioning Metastatic Thyroid Carcinoma in a Burn

Patient
According to Yoshiko Naito et. al. (1997), Thyrotoxicosis resulting from
functioning metastatic thyroid carcinoma is uncommon. It is suggested that the
mass of functioning metastatic tissue is crucial to the onset of thyrotoxicosis;
because of low inherent hormone-producing capacity, functioning metastatic
thyroid carcinoma produces thyrotoxicosis when the mass of tissue issufficiently
great to provide an excess of thyroid hormones. Unlike these reported cases,
sudden onset of thyrotoxicosis in our patient was characterized by the critical
failure of vital organs, known as thyroid storm. Thyroid storm caused by
functioning metastatic thyroid carcinoma is extremely uncommon, and its
pathogenesis perioperatively remains unclear.
In general, thyroid storm develops in those with untreated or undertreated

thyrotoxicosis. Our patient was receiving periodic thyroid function testing during
the 1-yr period before suffering the burn injury. He was shown to remain euthyroid
with levothyroxine replacement, which indicates that the mass of functioning
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metastatic tissue was not big enough to produce an excess of thyroid

hormones at the onset of the burn injury. It is well-known that conditions such as
surgery and extensive burns suppress host tumor immunity, resulting in
accelerated growth of carcinoma tissue in cancer patients. In our patient, newly
developed metastases in the cervical vertebrae were found. However, repeated
determination of thyroid hormone levels revealed that total T4 level remained
within or below the normal range after receiving the burn injury. It is therefore
unlikely that an excess of thyroid hormone production induced by growth of the
functioning metastatic tissue is the responsible mechanism of development of
thyroid storm in this patient. (Yoshiko Naito et. al. 1997)
Thyroid storm usually is associated with some precipitating events.

Situations known to trigger thyroid storm include surgery, infections, and trauma.
Although the exact mechanism of triggering thyroid storm has not been
completely elucidated, elevation in free thyroid hormone levels is suggested as a
cause. In the present patient, repeated determination of thyroid hormone levels
revealed major increases of free thyroid hormone levels after each surgical
procedure. Serum albumin level was markedly decreased at the onset of the
thyroid storm. Hypoalbuminemia is common in a patient of severe burn injury
with repeated surgical treatments. Surgery and severe burn injury are known to
induce major elevation of plasma interleukin-6 level. Interleukin-6 is reported to
inhibit production of transthyretin and thyroxine-binding globulin by hepatocytes.
It is suggested that transient deficiency of thyroid hormone-binding proteins, such
as transthyretin, thyroxine-binding globulin, and albumin, and resultant elevation
of free T3 and T4 levels are responsible for the thyroid storm in this patient.
(Yoshiko Naito et. al. 1997)
23
Laoag City
Tel. No. (077)-670-8609 to 10 Fax (077) 771-3814
VII. REFERENCES
Arosemena, M. A. (2018, January 2). Thyroid storm triggered by strangulation in a
patient with undiagnosed Graves’ disease. Publishing Open Access research
journals & papers |
Hindawi. https://www.hindawi.com/journals/crie/2018/4190629/
Burmeister, L. (2019, April 24). Coma in thyroid storm: Review of aggregated English-
language case reports. OUP
Academic. https://academic.oup.com/jes/article/3/7/1261/5476581
Davis, C. P. (2020, September 12). Thyroid storm causes, signs & symptoms.
MedicineNet.
https://www.medicinenet.com/thyroid_storm_symptoms_causes_and_treatment/vi
ews.htm
Gonzalo, A. (2021, March 5). Lydia hall: Care, cure, core nursing theory.
Nurseslabs. https://nurseslabs.com/lydia-e-halls-care-cure-core-theory/
Hinkle, J. L., & Cheever, K. H. (2018). Brunner and Suddarth’s textbook of medical-
surgical nursing (14th ed.). Wolters kluwer india Pvt.
Higuera, V. (2019, February 25). Thyroid storm: Symptoms, diagnosis, and causes.
Medical and health information.
https://www.medicalnewstoday.com/articles/312442#diagnosis
24
Laoag City
Tel. No. (077)-670-8609 to 10 Fax (077) 771-3814
Miller, A., & Silver, K. D. (2019, October 9). Thyroid storm with Multiorgan failure
treated with plasmapheresis. Publishing Open Access research journals & papers
| Hindawi. https://www.hindawi.com/journals/crie/2019/2475843/
Moore, K. (2018, September 28). Thyroid storm: Causes, symptoms, and diagnosis.
Healthline. https://www.healthline.com/health/thyroid-storm
Thyroid storm: Practice essentials, pathophysiology, etiology. (2021, April 2). Diseases
& Conditions - Medscape Reference.
https://emedicine.medscape.com/article/925147-overview
Pokhrel, B., Aiman, W., & Bhusal, K. (2021, July 21). Thyroid storm - StatPearls -
NCBI bookshelf. National Center for Biotechnology
Information. https://www.ncbi.nlm.nih.gov/books/NBK448095/
25

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NORTHWESTERN UNIVERSITY

College of Allied Health Sciences

ALTERNATIVE LEARNING ACTIVITIES

First Semester A.Y. 2021-2022

IV. DISCHARGE PLANNING 10

V. RELATED NURSING THEORY 12

VI. REVIEW OF RELATED LITERATURE/STUDIES 14

Patient X, female presents to the emergency room per wheelchair

Her past history showed no diagnosis of hypertension, diabetes mellitus or

➢ CBC: basic metabolic panel and lipase were all normal

➢ A thyroid ultrasound revealed diffuse heterogeneity consistent with

The objective of this activity is to provide information about thyroid storm,

Thyroid storm (thyrotoxic crisis) is a form of severe hyperthyroidism,

Thyroid storm accounts for about 1% to 2% of admissions for

IV. DISCHARGE PLANNING

Discharge planning is the process of transitioning a patient from one level

GOAL/OBJECTIVES DISCHARGE INSTRUCTION/

The goal of Medication is: • Advice the patient to continue

• Avoid eating excessive amounts of

• Provide comfort measures like

The primary purpose of theory in the profession of nursing is to improve

reflective technique. The cure which involves the administration of

Thyroid Storm Presenting as psychosis

and thyrotoxicosis presenting as psychosis, there are only a handful of cases

Coma in Thyroid Storm

Thyroid storm with Multiorgan Failure treated with plasmapheresis

According to Ann Miller and Kristi Silver (2019), Plasmapheresis is an

be used to reduced circulating thyroid hormone and treat refractory thyroid

Thyroid storm triggered by strangulation in a patient with undiagnosed

Case series: Rare cases of thyroid storm in COVID-19 patients

This pandemic disease has been associated with numerous autoimmune

considered as indicated. (Nasrin Milani et. al. 2021)

The Philippine Thyroid Diseases Study (PhilTiDeS 1): Prevalence of Thyroid

monitoring showed increased 24 hour mean heart rate and

Cardiorespiratory Failure in Thyroid Storm: Case Report and Literature

Thyroid storm is almost always fatal without proper treatment.

Thyroid Storm Due to Functioning Metastatic Thyroid Carcinoma in a Burn

In general, thyroid storm develops in those with untreated or undertreated

metastatic tissue was not big enough to produce an excess of thyroid

Thyroid storm usually is associated with some precipitating events.

Arosemena, M. A. (2018, January 2). Thyroid storm triggered by strangulation in a

patient with undiagnosed Graves’ disease. Publishing Open Access research

journals & papers |

language case reports. OUP

surgical nursing (14th ed.). Wolters kluwer india Pvt.

Medical and health information.

& Conditions - Medscape Reference.

NCBI bookshelf. National Center for Biotechnology

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