Related Subjects:
|Thyrotoxicosis and Hyperthyroidism
|Thyroid Storm - Thyrotoxic crisis
|Graves Disease (Thyrotoxicosis)
|Amiodarone and Thyroid disease
|Thyroid Surgery (Thyroidectomy)
|Hypothyroidism
|Hashimoto's thyroiditis
|DeQuervain's thyroiditis
|Subacute Thyroiditis
|Thyroid nodule
|Congenital Hypothyroidism
|Thyroid Function Tests and antibodies
|Post partum thyroiditis
|Sick Euthyroid Syndrome
|Thyroid Exam (OSCE)
|Thyroid Gland anatomy and Physiology
|Thyroid Cancer
โก Thyroid storm is a rare, life-threatening endocrine emergency caused by excess thyroid hormone activity. Mortality remains high despite treatment (10โ20%). โ ๏ธ Avoid aspirin as an antipyretic โ it displaces thyroxine from binding proteins, worsening the crisis.
๐ About
- ๐งพ First described in 1926.
- ๐ก๏ธ Life-threatening escalation of thyrotoxicosis, usually triggered by stress or illness.
- Occurs in ~2% of hyperthyroid patients, often on a background of untreated or undertreated Gravesโ disease.
๐งฌ Aetiology
- Gravesโ disease (most common).
- Multinodular goitre or thyroiditis.
- Post-thyroidectomy in patients still thyrotoxic.
๐ฅ Precipitants
- Intercurrent illness: infection, myocardial infarction, diabetic ketoacidosis.
- Radioiodine therapy or abrupt withdrawal of antithyroid drugs.
- Surgery, trauma, or childbirth.
- Certain immunotherapies (e.g. IL-2, interferon-ฮฑ).
๐ฉบ Clinical Features
- ๐ Hyperadrenergic state: tachycardia, atrial fibrillation, sweating, pyrexia >40 ยฐC.
- ๐ก Neuropsychiatric: agitation, delirium (hypo/hyperactive), psychosis, seizures.
- โก Cardiovascular: palpitations, high-output heart failure, shock.
- ๐ฉธ GI/hepatic: abdominal pain (mimicking acute abdomen), jaundice.
- ๐ Eye signs and goitre suggest underlying Gravesโ disease.
- NB: In the elderly, may be โapatheticโ with lethargy, rather than agitation.
๐ Differentials
- Septic shock or systemic infection.
- Other causes of delirium (delirium tremens, anticholinergic toxicity).
- Acute pulmonary oedema or cardiogenic shock.
๐งช Investigations
- ๐งพ Bloods: FBC, U&E, Ca, LFTs, ESR/CRP.
- ๐ Thyroid panel: T3/T4 (raised), TSH (suppressed) โ confirms diagnosis retrospectively.
- ๐ ECG for arrhythmias (often AF).
- ๐ธ CXR if pneumonia suspected.
- Thyroid autoantibodies for underlying cause.
๐ ๏ธ โThe 5 Bsโ Treatment Principles
- ๐ Block hormone synthesis โ Carbimazole, Propylthiouracil (PTU).
- ๐ซ Block hormone release โ Potassium iodide (given 1 hr after antithyroid drugs).
- โธ๏ธ Block T4โT3 conversion โ PTU, propranolol, corticosteroids, amiodarone (rarely).
- ๐ Beta-blockade โ Propranolol (rate control, symptom relief).
- ๐ Block enterohepatic circulation โ Cholestyramine.
๐ Management
- ABC resuscitation, ITU/HDU involvement, oxygen, IV access, cooling measures.
- IV fluids: start with 1L 0.9% NaCl over 2โ4 hrs; correct electrolytes.
- Antipyresis: IV paracetamol (avoid aspirin).
- Sedation for agitation: Chlorpromazine (also reduces temperature) or Diazepam.
- Antithyroid therapy:
- PTU 200 mg PO/NG, then 250 mg q6h (preferred, as it reduces T4โT3).
- Carbimazole 20 mg q6h if PTU unavailable.
- Potassium iodide 0.3 ml PO TDS (1 hr after antithyroid drug).
- Steroids: Dexamethasone 2 mg q6h or Hydrocortisone 100 mg q8h (reduces T4โT3 and dampens autoimmune process).
- Adjuncts: Pabrinex if malnourished; Plasmapheresis in refractory cases.
โ ๏ธ Complications
- Life-threatening shock (exclude cardiomyopathy, treat sepsis).
- DIC and multi-organ failure.
- Congestive cardiac failure (may require diuretics, nitrates, digoxin, CPAP).
- Status epilepticus (diazepam, phenytoin/fosphenytoin).
๐ References
