Yet more FOAMed gospel from Scott Weingart in NYC. Below is the podcast and show notes, but for the full experience check out the actual site for the comments: www.emcrit.org/podcasts/thyroid-storm/
Not a topic of specific expertise for me, but I wanted to get all of the info in one place for future use–Thyroid Storm
Most of the Below Information is from:
(Chiha, Samarasinghe, and Kabaker 2013)*
EMRAP June 2010 Stuart Swadron Interviews Jonathan LoPresti
Diagnosing Thyroid Storm
From Jonathan LoPresti
Hyperthyroid
Fever
AMS-trouble concentrating all the way to coma
Sympathetic Surge
Precipitating Event
Elderly-internalized beta receptors may have more subtle presentations of storm
from JICM 2015;30:131
Storm Score
>45 is almost surely storm,
25-44 is suggestive,
<25 is unlikely
(Endocrinol Metab Clin North Am. 1993 Jun;22(2):263-77)
Labs
TSH, Free T3, Free T4
Blood Cultures
May see low Cr and High Ca
Won’t mount normal WBC increase in hyperthyroidism
May also have thrombocytopenia
Treatment
Block New Production
The thionamides: Methimazole and PTU; the latter may be preferred as it also blocks peripheral T4 to T3 conversion
PTU 500-1000 mg load then 250 mg Q4 hours (Guidelines from AACE (endo group))
Methimazole 60-80 mg qday, divided into doses q4-6 hrs (20 mg Q6)
Block Thyroid Hormone Release
Wolf-Chaikoff effect blocks iodide binding to thyroglobulin once critical levels of iodide are reached
SSKI 5 drops PO q6
or
Lugol’s Solution 8 drops PO q 6
or Sodium Iodide 0.5 mg IV Q 12 hours
Don’t give until 60 minutes after thionamides
Lithium can be substituted in patients who will undergo radioactive iodide treatment or patients allergic to Iodides, use 300 mg q 6-8 but personally, I would consult a endocrinologist before going this road. (J Inten Care Med 2015;30(3):131)
Treat Volume Loss
These patients have large insensible losses and diuresis. Even in the setting of seeming heart failure, they may need fluids as the heart failure is high-output.
Treat Sympathetic Surge
Propanolol 1 mg IV (test dose) then Propranolol 1-2 mg q 15 minutes until HR of 100 bpm
then start Propanolol drip at whatever dose it took to get IV load control (Max 3-5 mg/hr)
Propranolol also blocks T4 to T3 conversion
or titrate esmolol for HR of 100 bpm, but selective B1 means may be less effective
Block Peripheral Conversion and Shield from Adrenal Insufficiency
Dexamethasone 4 mg IV Q 6 hours
or
Hydrocortisone 300 mg IV and then 100 mg q 8 hours
Not Available in the US?
Oral cholecystographic agents (HIDA Scan Contrast) 2g loading dose followed by 1g q day
Temperature regulation
Do not aggressively cool these patients; this is contraindicated because it can lead to further vasoconstriction