25. Thyroid Storm

Question 1

Clinical features

Answer 1

Cardiovascular symptoms in many patients include tachycardia to rates that can exceed 140 beats/minute and congestive heart failure. Hypotension, cardiac arrhythmia, and death from cardiovascular collapse

Hyperpyrexia

Agitation, anxiety, delirium, psychosis, stupor, or coma

Question 2

Invx

Answer 2

FBC
- raised WCC

U+E
Hypokalaemia
Hypo Mg
Hypercalcaemia
Hyperglycaemia

TFT
Low TSH
Elevated T3 + T4

LFts
ALT AST ALP Bili up

Question 3

Invx Labs

Answer 3

ABG
mix resp and met acidosis

Peripheral BCX

ECG
Arrhythmia
LVH?

CXR
Cardiomegaly
APO

Question 4

Immediate management

Answer 4

Medical emergency
- Rx not delayed for biochem confirmation

ABC 100% O2

Intubate + Ventilate if severe respiratory compromise

Fluid Resus
IV crystalloid therapy

Correct electrolyte abnorm
K MG

Active cooling
fluid / cold blanket / bladder irrigating

Invasive CV monitoring

Transfer to CCM

BSA ?infectious trigger

Question 5

Immed mx

Drugs

Answer 5

1. Hydrocort 100mg IV QDS
   correct deficit caused by thyrotoxicosis
   decrease peripheral conversion t4->t3
2. Drugs alter Thyroid Hormone metabolism
3. Beta-block
4. Carbimazole
5. Propylthiouracil
6. K Iodide

Other therapy
Dantrolene if hyperpyrexia
reserpine 
guanethidine if propranolol resistant
PLEX

Question 6

Beta blockers

Answer 6

IV B Blockers
- Reduce T4 conversion
- Red catecholamine hypersensitivity
Block peripheral thyroid hormone effects

Propranolol 0.5mg increments to max 10mg

Metoprool 2-5mg increments to max 20mg

Esmolol 0.25-0.5mg/kg

Question 7

Other drugs altering thyroid metab

Answer 7

1. Carbimazole
   Block thyroid hormone synthesis
   60-120 PO
2. Propylthiouracil
   Blocks thyroxine synthesis
   Conversion T4->T3
   200mg 4h
3. K Iodide
   Block synthesis and release of thyroid hormones
   0.3mL lugols iodine
   Dilute to 50ml TDS Ng before propyhlthio (1h prior to 2.)
4. Anti arryh
   Amio / Dig