Thyroid Storm

Question 1

Thyrotoxicosis symptoms

Answer 1

Weight loss despite increased appetite
Anxiety\Nervousness\Emotional liability
Fatigue
Heat intolerance
Diaphoresis\Increased perspiration
Palpitations
Dyspnea
Difficulty getting out of chair\ Combing hair (Weakness)
Frequent bowel movements\Diarrhea
Amenorrhea
Decreased libido

Question 2

Thyrotoxicosis signs

Answer 2

Cachexia
Hyperthermia
Anxious\Agitated
Tremor
Hypertension
Widened pulse pressure
Thyroid mass\Goiter
Tachycardia (Sinus tachycardia, atrial fibrillation)
Proximal muscle weakness
Diaphoresis\Damp skin
Gynecomastia
Additional Signs Associated with Graves Disease
Proptosis
Chemosis
Periorbital edema
Diplopia\Extra ocular muscle dysfunction
Non-pitting pretibial edema
Diffusely enlarged thyroid gland

Question 3

Medications associated with thyrotoxicosis

Answer 3

Amiodarone, IFN alpha, Lithium, Interleukin 2, Iodinated contrast, Radioactive iodine, Increased iodine intake

Question 4

How is thyroid storm related to thyrotoxicosis?

Answer 4

thyroid storm is part of the spectrum of thyrotoxicosis and it can be difficult to distinguish from severe thyrotoxicosis.

Question 5

Common thyroid storm triggers

Answer 5

Infection
Discontinuing medications for hyperthyroidism
Myocardial infarction
Stroke
Thyroid surgery
Self-administration of thyroxine or thyroid supplements
Treatment with radioactive iodine
Pregnancy
Diabetic ketoacidosis
Non-thyroid surgery
Trauma
Iodinated contrast exposure

Question 6

Common thyroid lab findings

Answer 6

Most patients will demonstrate elevated free T4 and T3 levels and a low or undetectable TSH level.

Question 7

Why should salicylate be avoided in a thyroid storm?

Answer 7

Salicylates should be avoided as they will displace T4 and T3 from thyroxine binding globulin and result in increased free hormone levels and potentially worsen symptoms.

Question 8

Medications used in treatment of thyroid storm

- Stop the production

Answer 8

• PTU: Inhibits T4 & T3 production by inhibiting iodination of thyroglobulin. Blocks T4 to T3 conversion by peripheral tissues.
• Methimazole: block new hormone synthesis

Question 9

Medications used in treatment of thyroid storm

- Inhibit hormone release (Don’t start until at least an hour after PTU or Methimazole administration)

Answer 9

• Potassium Iodide and Lugol’s solution block the release of hormone from the thyroid.
• Sodium Ipodate, and Iopanoic acid block release of hormone from the thyroid and block T4 to T3 conversion.

Question 10

Medications used in treatment of thyroid storm

- Inhibit peripheral effects of thyroid hormone

Answer 10

• Propranolol: Reduces symptoms due to increased adrenergic tone.
  Inhibits T4 to T3 conversion.
• Esmolol: Reduces symptoms due to increased adrenergic tone. May be preferred in setting of possible heart failure due to short half-life.

Question 11

Medications used in treatment of thyroid storm

- Glucocorticoids

Answer 11

• Dexamethasone (preferred): Inhibit the peripheral conversion of T4 to T3. Promote vascular stability. Treat relative possible relative adrenal insufficiency.
• Hydrocortisone: Inhibit the peripheral conversion of T4 to T3. Promote vascular stability. Treat relative possible relative adrenal insufficiency.