Thyroid storm


















Infection/sepsis
Surgery
Acute coronary syndrome/myocardial infarction
Cerebral vascular accident
Trauma (especially neck trauma)
Medication noncompliance
Thyroid hormone ingestion
Iodine contrast



Presentation



  • 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
U+2265104 30
Tachycardia (beats/minute)
90–109 5
110–119 10
120–129 15
130–139 20
U+2265140 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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Feb 17, 2017 | Posted by in CRITICAL CARE | Comments Off on Thyroid storm
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