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 (first described in 1926) is an acute, life-threatening complication of hyperthyroidism that presents with multi-system involvement. It is an endocrine emergency 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. The mortality associated with thyroid storm is estimated to be 8-25% despite modern advancements in its treatment and supportive measures.

Thyroid storm:

• Most commonly seen in the context of underlying Graves' disease but can complicate thyrotoxicosis of any aetiology.
• Accounts for about 1% to 2% of admissions for hyperthyroidism.

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. Presenting features:

• 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
• 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.

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, eg 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

Thyroid storm is most commonly associated with underlying Graves' disease, although has been reported with autonomous thyroid nodular disease.

Traditionally, the condition was experienced frequently following thyroidectomy for thyrotoxic state, but modern treatments aimed at reducing preoperative thyroid output and hormone stores have dramatically reduced this complication.

The rare transition to a state of thyroid storm usually requires a second superimposed insult. Most commonly this is infection, although trauma, surgery, myocardial infarction (MI), diabetic ketoacidosis (DKA), pregnancy and parturition have been reported as causes.

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/