Thyroid Emergencies

Dr. AM Iyagba
Medicine Department,
Faculty of Clinical Sciences,
College of Health Sciences,
University of Port Harcourt.
 Thyroid emergencies includes:
• Thyroid storm

• Myxoedema coma

• Thyrotoxic periodic paralysis

 Thyroid storm
• This is an acute life-threatening exaggeration of the
usual symptoms of hyperthyroidism in patients with
severe thyrotoxicosis.
• Precipitants:
 Thyroid or non-thyroidal surgery
 Trauma
 Infection
 Acute iodine load
 Poor pre-operative preparation of hyperthyroid
patients
 Clinical features of thyroid storm
• General
 Hyperpyrexia
 Diaphoresis
• Cardiovascular system
 Severe tachycardia
 Congestive heart failure
• Gastrointestinal system
 Severe nausea
 Vomiting or diarrhea
 Hepatic failure with jaundice
• Central nervous system
 Agitation
 Delirium
 Psychosis
 Stupor or coma
 Rx of thyroid storm
• Therapeutic options for thyroid storm are the same as
for uncomplicated hyperthyroidism,. y except that the
drugs are given in higher doses and more frequently.
• Admit into ICU for full supportive care which entails:
 IV fluids
 Antipyretics for hyperpyrexia
 Antibiotics
 Diuretics/digoxin if in heart failure
 Anti-thyroid drugs
 Beta blockers
 Steroids
 Therapeutic regimen for thyroid storm
This consists of multiple drugs with different MOA
1. ß-blockers
 To control symptoms induced by increased adrenergic tone
 Propranolol: 40-120 mg 6 hourly
2. Thionamide
 To block new hormone synthesis
 PTU: 150-250 mg 6 hourly
3. Iodinated radio-contrast agent
 To inhibit the peripheral conversion of T4→T3
 Iopodate: 500mg daily
4. Iodine solution
 To help block the release of thyroid hormones
 Lugol’s iodine 10 drop tds
5. Glucocorticoids
 To help reduce the T4 to T3 conversion & possibly Rx autoimmune Grave’s
disease
 IV hydrocortisone 50 mg 6hourly
Myoxedema coma
• Myxoedema coma is a life-threatening
condition characterized by an exacerbation of
the manifestations of hypothyroidism.
• Usually occurs in elderly patients with
untreated or poorly treated hypothyroidism
• Should be treated aggressively as it has a high
mortality of up to 80%
• Patients should be monitored closely in ICU
• Blood should be taken for free T4, T3, TSH and
cortisol before starting treatment
 Precipitants
• Prolonged cold exposure
• Infection
• Trauma
• Myocardial infarction
• Congestive heart failure
• Respiratory failure
• Pulmonary embolism
• Stroke
• Gastrointestinal bleeding
• CNS depressant drugs
Treatment
1. Thyroid hormone replacement
 IV L-thyroxine 300-500 µg stat then IV 50-100
µg daily until patient can take oral L-thyroxine
 If no improvement within 24-48 hrs, add IV T3
(10 µg 8 hourly)
2. IV Hydrocortisone: 100mg 6-8 hrly must be
given until possible coexisting adrenal
insufficiency can be excluded.
3. IV fluids
4. IV glucose as appropriate
5. Correct Hypothermia
 Using a heating blanket
 Aim for hourly rise of 0.5 degree celcius in core
temperature.
 Rapid external warming can cause inappropriate
vasodilatation and cardiovascular collapse.
6. Rx possible precipitating factors such as infection
with broad spectrum antibiotics
7. Oxygen
8. ±Mechanical ventilation