Thyroid Storm (Thyroid Crisis)

Original Editors - Chelsea Reed & Tory Schwartz from Bellarmine University's Pathophysiology of Complex Patient Problems project.

Top Contributors - Chelsea Reed, Elaine Lonnemann, Lucinda hampton, Kim Jackson, WikiSysop and Adam Vallely Farrell  

Introduction

Thyroid hormones: control metabolism

Thyroid storm, also known as thyrotoxic crisis, is an acute, life-threatening complication of hyperthyroidism that presents with multi-system involvement. The mortality associated with thyroid storm is estimated to be 8-25% despite modern advancements in its treatment and supportive measures.

Thyroid storm is an endocrine emergency 9first described in 1926) and remains a diagnostic and therapeutic challenge. No laboratory abnormalities are specific to thyroid storm, and the available scoring system is based on the clinical criteria.

A throid storm is usually seen following illness, trauma, surgery or other major physiological stress in an individual with existing thyrotoxicity. Thyroid storm accounts for about 1% to 2% of admissions for hyperthyroidism.

Individuals with a history of eg: hyperthyroidism; Graves' disease; toxic multinodular goiter; or adenoma are at the highest risk for experiencing a thyroid storm. 

Characteristics/Clinical Presentation

Signs and symptoms hyperthyroidism

Presentation of thyroid storm is an exaggerated manifestation of hyperthyroidism, with the presence of an acute precipitating factor.

Fever of 104 F to 106 F with diaphoresis is a key presenting feature, cardiovascular involvement (including tachycardia, heart failure, arrhythmia), central nervous system (CNS) manifestations, and gastrointestinal symptoms are common.

Physical examination findings may include high temperature, tachycardia, orbitopathy, goiter, hand tremors, moist and warm skin, hyperreflexia, systolic hypertension, and jaundice.

Associated Co-morbidities

• Hyperthyroidism
• Congestive heart failure
• Coronary artery disease
• Sjogren’s syndrome
• Rheumatoid arthritis
• Psoriatic arthritis
• Chronic periarthritis
• Myasthenia gravis

Management

Thyroid storm is a rare life-threatening medical emergency and is difficult to diagnose. An interprofessional team including an intensivist, cardiologist, endocrinologist, internist, emergency department physician, and infectious disease expert is recommended.

These patients are best managed in the ICU. Nurses need to be fully aware of the potential complications and notify the physician if there is any change in the hemodynamic status.

Treatment of thyroid storm consists of supportive measures eg intravenous (IV) fluids, oxygen, cooling blankets, acetaminophen, as well as specific measures to treat hyperthyroidism. If any precipitating factors, like for example an infection, are present, they need to be taken care of first. Patients with thyroid storm must be admitted to the intensive care unit with close cardiac monitoring and ventilatory support as needed.

Etiology/Causes

Thyrotoxicity occurs when there are abnormally high levels of thyroid hormone circulating within the body, most often due to overactivity of the thyroid gland. Graves’ disease is the most common form of thyrotoxicosis that leads to a thyroid storm. Other causes include multinodular goiter and toxic adenoma. The full pathophysiology of thyroid storm is unknown, but the exposure of increased numbers of beta1-adrenergic receptors to heightened catecholamine levels during times of stress is thought to play a role. Another cause is thought to be involved with the displacement of free thyroid hormones by inhibiting cytokines during illness.

Precipitating Factors:

• Trauma
• Infection
• Surgery
• Emotional/Physiological Stress
• Diabetic Ketoacidosis
• Pregnancy
• Pulmonary Embolism
• Myocardial Infarction
• Pneumonia
• Upper respiratory tract infection
• Enteric infections

Physical Therapy Management

Requires immediate medical attention

When medical attention is required?
In a patient experiences the following, especially those with a history of Hyperthyroidism or Graves’ Disease:

• Tachycardia
• Palpitations
• Hyperthermia
• Excessive sweating
• Abdominal pain
• Nausea and vomiting
• Altered consciousness

What should be monitored during treatment session?
Vital signs including: blood pressure, heart rate, and respiratory rate.

Other signs: excessive sweating, shortness of breath, abnormal tenderness with palpation of the thyroid gland, abnormal heart sounds, fever, tremor, and any of the clinical signs listed above.

Hyperthyroidism and Exercise (see hyperthyroidism)

Case Reports/ Case Studies

1. Intraoperative Thyroid Storm: A Case Report

http://eds.a.ebscohost.com/ehost/pdfviewer/pdfviewer?sid=be2eb971-e9c0-47be-8fa3-2d63ac084f75%40sessionmgr4005&vid=12&hid=4210
Case report of an 18 year old female who was 1 year post diagnosis of Graves’ Disease and was underwent elective thyroidectomy surgery. 30 minutes into the surgery the patient’s heart rate and temperature started to rise. Treatment was performed to combat the thyroid crisis and the surgery to remove her thyroid was completed.

2.Thyroid Storm Precipitated by Duodenal Ulcer Perforation

http://eds.a.ebscohost.com/ehost/pdfviewer/pdfviewer?sid=be2eb971-e9c0-47be-8fa3-2d63ac084f75%40sessionmgr4005&vid=12&hid=4210
Thyroid storm triggered by a gastrointestinal perforation in a 55 year old Japanese man. Admitted to the hospital for leg edema and acute severe abdominal pain. On arrival he presented with tachycardia with a goiter, altered consciousness, atrial fibrillation, and swelling of the abdomen.

3. Thyroid Storm during induction of anesthesia http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3506864/
Case report of a 50 year old woman who experienced a thyroid storm during anesthesia induction for a humeral fracture repair. Patient presented with no history of hyperthyroidism nor abnormal signs preoperatively. However, reported weight loss, intermittent palpitations, and hand tremors for the past year.

Resources

http://thyroidmanager.org
http://endocrinediseases.org/
http://www.thyroid.org/
https://www.nahypothyroidism.org/