|Acute coronary syndrome/myocardial infarction|
|Cerebral vascular accident|
|Trauma (especially neck trauma)|
|Thyroid hormone ingestion|
- 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.
- Marked tachycardia, often with ventricular rates exceeding 140 bpm.
- Fever, temperatures sometimes exceeding 41°C (106°F).
- GI symptoms, such as abdominal pain, nausea, vomiting, diarrhea.
- CNS dysfunction, agitation, confusion, delirium.
- 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.
- Evaluate for the presence of atrial fibrillation, other cardiac arrhythmias, or evidence of acute myocardial ischemia.
- The most common cardiac rhythm is sinus tachycardia.
- Consider bedside echocardiography if suspecting pericardial effusion or significant cardiac dysfunction.
- 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)|
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