The broad clinical picture is one suggestive of a hypermetabolic state with increased beta-adrenergic activity.
Often more than one disease process may be occurring at once, which makes rapid identification of thyroid storm very difficult. The key is to have a high index of suspicion.
Classic presentation
Marked tachycardia, often with ventricular rates exceeding 140 bpm.
Fever, temperatures sometimes exceeding 41°C (106°F).
Diaphoresis.
GI symptoms, such as abdominal pain, nausea, vomiting, diarrhea.
CNS dysfunction, agitation, confusion, delirium.
Critical presentation
High-output cardiac failure and shock.
Atrial fibrillation with rapid ventricular response.
Severely obtunded state, coma, seizure.
Diagnosis and evaluation
The diagnosis of thyroid storm is made based on clinical findings and laboratory analysis.
Burch and Wartofsky scoring system
Given the spectrum of illness, Burch and Wartofsky developed a scoring system to help clinically distinguish uncomplicated thyrotoxicosis from impending thyroid storm and true thyroid storm (Table 60.2).
A score of 45 or more is highly suggestive of thyroid storm, a score of 25–44 is suggestive of impending thyroid storm, and a score below 25 makes the diagnosis of thyroid storm unlikely.
Laboratory testing
Laboratory evaluation is primarily directed at assessing the severity of the disease and searching for potential precipitants.
TSH, T3, T4, free T4
CBC, basic metabolic profile, lactate, hepatic function panel, lipase.
Cardiac markers, brain natriuretic peptide (BNP).
Blood, urine and possibly CNS cultures/analysis.
A normal TSH virtually excludes the diagnosis of thyroid storm.
ECG
Evaluate for the presence of atrial fibrillation, other cardiac arrhythmias, or evidence of acute myocardial ischemia.
The most common cardiac rhythm is sinus tachycardia.
Echocardiography
Consider bedside echocardiography if suspecting pericardial effusion or significant cardiac dysfunction.
Imaging
Chest radiography to rule out pneumonia and to evaluate for evidence of congestive heart failure (CHF).
Consider CT of the head to assess for other potential etiologies of altered mental status.
Table 60.2.Burch and Wartofsky scoring system for thyroid storm
Thermoregulatory dysfunction (°F)
99–99.9
5
100–100.9
10
101–101.9
15
102–102.9
20
103–103.9
25
104
30
Tachycardia (beats/minute)
90–109
5
110–119
10
120–129
15
130–139
20
140
25
CNS effects
Mild agitation
10
Delirium/psychosis/lethargy
20
Seizure/coma
30
Heart failure
Pedal edema
5
Bibasilar rales
10
Atrial fibrillation
10
Pulmonary edema
15
Gastrointestinal-hepatic dysfunction
Diarrhea/nausea/vomiting/abdominal pain
10
Unexplained jaundice
20
Precipitant history
Positive
10
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