Thyroid Storm (Thyroid Crisis): Difference between revisions

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<div class="noeditbox">Welcome to [[Pathophysiology of Complex Patient Problems|PT 635 Pathophysiology of Complex Patient Problems]] This is a wiki created by and for the students in the School of Physical Therapy at Bellarmine University in Louisville KY. Please do not edit unless you are involved in this project, but please come back in the near future to check out new information!!</div><div class="editorbox">
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'''Original Editors '''- [[Pathophysiology of Complex Patient Problems|Students from Bellarmine University's&nbsp;Pathophysiology of Complex Patient Problems project.]]  
'''Original Editors '''- [[Pathophysiology of Complex Patient Problems|Chelsea Reed &amp; Tory Schwartz from Bellarmine University's&nbsp;Pathophysiology of Complex Patient Problems project.]]  


'''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}} &nbsp;  
'''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}} &nbsp;  
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== Definition/Description  ==
== Introduction ==
[[File:Thyroid and release.jpeg|thumb|Thyroid hormones: control metabolism|alt=|363x363px]]
[[Thyroid Gland|Thyroid]] storm (first described in 1926) is an acute, life-threatening complication of [[hyperthyroidism]] that presents with multi-system involvement. It is an [[Metabolic and Endocrine Disorders|endocrine]] emergency and remains a diagnostic and therapeutic challenge. No [[Laboratory Tests|laboratory]] abnormalities are specific to thyroid storm, and the available scoring system is based on the clinical criteria. <ref>Chiha M, Samarasinghe S, Kabaker AS. [https://pubmed.ncbi.nlm.nih.gov/23920160/ Thyroid storm: an updated review]. Journal of intensive care medicine. 2015 Mar;30(3):131-40.Available: https://pubmed.ncbi.nlm.nih.gov/23920160/ (accessed 23.2.2022)</ref> The mortality associated with thyroid storm is estimated to be 8-25% despite modern advancements in its treatment and supportive measures.<ref name=":0">Pokhrel B, Aiman W, Bhusal K. [https://www.ncbi.nlm.nih.gov/books/NBK448095/ Thyroid storm.] Available: https://www.ncbi.nlm.nih.gov/books/NBK448095/<nowiki/>(accessed 23.2.2022)</ref>


An acute, life-threatening exacerbation of thyrotoxiosis. This condition is rare now due to more efficient diagnosis and treatment of thyrotoxicosis in addition to improved management pre and post surgery. When it does occur, it is following illness, trauma, surgery or other major physiological stress in an individual with existing thyrotoxicity. Thyroid storm occurs most commonly in those with uncontrolled or undiagnosed thyrotoxicity with an added precipitating factor. Individuals with a history of [[Hyperthyroidism|hyperthyroidism]], [[Grave's Disease|Graves' disease]], toxic multinodular goiter, adenoma or any other cause of endogenous thyrotoxicity are at the highest risk for experiencing a thyroid storm. <ref name="2" /><ref name="4" /><ref name="5" /><br>[[Image:Thyroid system pic.png|center]]<br>
Thyroid storm:


== Prevalence  ==
* Most commonly seen in the context of underlying [[Graves' Disease|Graves']] disease but can complicate thyrotoxicosis of any aetiology.<ref name=":1">Carroll R, Matfin G. Endocrine and metabolic emergencies: thyroid storm. Therapeutic advances in endocrinology and metabolism. 2010 Aug;1(3):139-45. Available:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3475282/ (accessed 23.2.2022)</ref>
* Accounts for about 1% to 2% of admissions for hyperthyroidism.<ref name=":0" />


Rare, but high mortality rates at 10-20%.<ref name="1" /> Currently, incidence may be as low as 0.2 cases/100,000 population.<ref name="5" /> More common in women than men (10:1).&nbsp;<ref name="11" /><br><br>
== Characteristics/Clinical Presentation ==
[[Image:Signs and symptoms hyperthyroidism.png|alt=|thumb|Signs and symptoms hyperthyroidism]]Presentation of thyroid storm is an exaggerated manifestation of hyperthyroidism, with the presence of an acute precipitating factor. Presenting features:  


== Characteristics/Clinical Presentation ==
* [[Fever]] of 104 F to 106 F with diaphoresis is a key presenting feature,  
* [[Cardiovascular Disease|Cardiovascular]] involvement (including [[Heart Arrhythmias: Assessment|tachycardia]], [[Heart Failure|heart failure]], arrhythmia), 
* [[Introduction to Neuroanatomy|Central nervous system]] (CNS) manifestations
* Gastrointestinal symptoms are common.


Classic presentation characterized by signs and symptoms of hypermetabolism including: <sup>[1] [3] [5]</sup>  
Physical examination findings may include high temperature, tachycardia, orbitopathy, goiter, hand tremors, moist and warm skin, hyperreflexia, systolic [[hypertension]], and jaundice.<ref name=":0" />


*Severe tachycardia
== Etiology ==
*Elevated blood pressure
Thyroid storm is most commonly associated with underlying Graves' disease, although has been reported with autonomous thyroid nodular disease.  
*Heart failure
*Peripheral edema
*Pulmonary edema
*Chest pain
*Hyperthermia (up to 105.3℉ or 40.7℃)
*Restlessness
*Agitation
*Delirium or psychosis
*Jaundice
*Abdominal pain
*Nausea and vomiting
*Diarrhea
*Profuse sweating
*Dehydration
*Tremor
*Coma
 
Central Features:<sup>[4]</sup>


*Thyrotoxicosis
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.
*Abnormal CNS function
*Fever
*Tachycardia (above 130bpm)
*GI tract symptoms
*Evidence of impending or present CHF


Elderly patients can have an atypical presentation characterized by: <sup>[1] [5]</sup>  
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.<ref name=":1" />


*Apathy
== Management==
*Stupor
[[File:Icu.jpg|thumb|360x360px|Throid storm managed in ICU]]
*Weakness
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.
*Cardiac failure
*Coma
*Minimal signs of thyrotoxicity
*Absent or low fever


[[Image:Signs and symptoms hyperthyroidism.png|center]]<br>
These patients are best managed in the [[The Intensive Care Unit|ICU]]. Nurses need to be fully aware of the potential complications and notify the physician if there is any change in the hemodynamic status.


Musculoskeletal Manifestations:<br>See [[Hyperthyroidism|hyperthyroidism]]<br>
Treatment of thyroid storm consists of supportive measures eg intravenous (IV) fluids, [[Oxygen Therapy|oxygen]], cooling blankets, acetaminophen, as well as specific measures to treat hyperthyroidism. If any precipitating factors, eg an [[Infectious Disease|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 [[Ventilation and Weaning|ventilatory]] support as needed.<ref name=":0" />
 
== Associated Co-morbidities  ==
 
*Hyperthyroidism
*Congestive heart failure
*Coronary artery disease
*Sjogren’s syndrome
*Rheumatoid arthritis
*Psoriatic arthritis
*Chronic periarthritis
*Myasthenia gravis <sup>[3]</sup><br>
 
== Medications&nbsp;<ref name="10" /> <ref name="11" /><ref name="10">Awad, N PharmD. Thyroid Storm: Treatment Strategies. Academic Life in EM. http://www.aliem.com/2013/thyroid-storm-treatment-strategies/ Nov 11, 2013. (Accessed 9 April 2016)</ref>  ==
 
'''Thionamide: blocks the production/release of the thyroid hormone, as well as the conversion of T4-T3.'''<br>Types:
 
*Propylthiouracil (PTU)
*Methimazole(MMI)
 
'''Iodine: blocks the conversion of T4-T3. '''<br> Types:
 
*Saturated solution potassium iodine (SSKI)
*Lugol’s Solution
 
IMPORTANT: This MUST only be given 1 hour after PTU has been administered. Iodine is a substrate in the production of the thyroid hormone and could make the situation worse if given before the production has been stopped with the use of PTU.
 
'''Beta Blocker: blocks the sympathetics peripherally'''<br>Types:
 
*Propanolol
*Esmolol
 
'''Steroids: block the peripheral conversion of T4 to T3 and in addition boosts the hypothalamic pituitary access.'''<br>Types:
 
*Hydrocortisone
*Decadron<br><br>
 
== Diagnostic Tests/Lab Tests/Lab Values  ==
 
Any signs of end organ dysfunction may be seen. Burch and Wartofsky suggested a scoring system to illustrate common features that can be seen when thyrotoxicosis has progressed enough to be considered a thyroid storm (Table 1). <sup>[1]</sup>
 
[[Image:Diagnostic Criteria for Thyroid Storm.PNG]]<br>
 
IF lab tests are performed TSH values with be low to undetectable and T4 will be high. <sup>[<ref name="11" /></sup><br><br>
 
== 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. <sup>[1]</sup>
 
Precipitating Factors:<ref name="2" /><sup>&nbsp;[3] [4]</sup>
 
*Trauma
*Infection
*Surgery
*Emotional/Physiological Stress
*Diabetic Ketoacidosis
*Pregnancy
*Pulmonary Embolism
*Myocardial Infarction
*Pneumonia
*Upper respiratory tract infection
*Enteric infections<br><br>
 
== Systemic Involvement  ==
 
Systemic Manifestations of Hyperthyroidism<sup>[1] <ref name="2" />&nbsp;[3] [4] [5]</sup>
 
[[Image:Thyroid Storm Systemic.PNG|center]]<br>
 
== Medical Management (current best evidence)&nbsp;<ref name="10" /><ref name="9">Goodman CG, Synder TE. Differential Diagnosis for Physical Therapists: Screening for Referral. 4th ed. St. Louis MO: Saunders, Elsevier, 2007.</ref><sup>&nbsp;<ref name="11" /></sup>  ==
 
Three main goals for medicinal treatment of a Thyroid Storm:
 
#Blocking the production and release of the thyroid hormone
#Blocking the sympathetic flow
#Blocking the conversion of T4 to T3
 
Medication that satisfy these goals include:
 
*Thionamides
*Iodines
*Beta Blockers
*Steroids
 
Supportive Care management
 
*Hyperkinesis- Benzodiazepine
*Hyperthermia- Cooling blankets
*Dehydration- IVF, electrolytes
*Fever- tylenol
 
Address the precipitating stressor<br>
 
== Physical Therapy Management (current best evidence)  ==


== Physical Therapy Management ==
[[File:Clinicians in Intensive Care Unit.jpg|thumb|Clinicians in Intensive Care Unit]]
Requires immediate medical attention  
Requires immediate medical attention  


'''When medical attention is required?<ref name="7" />'''<sup>]<ref name="8">Park JT, Lim HK, Park JH, Lee KH. Thyroid storm during induction of anesthesia. Korean Journal of Anesthesiology. 2012;63(5):477-478. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3506864/ (accessed 9 April 2016)</ref> <ref name="9" /></sup><br>In a patient experiences the following, especially those with a history of Hyperthyroidism or Graves’ Disease:  
When medical attention is required?: In a patient experiences the following, especially those with a history of Hyperthyroidism or Graves’ Disease:  


*Tachycardia  
*Tachycardia  
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*Altered consciousness
*Altered consciousness


'''What should be monitored during treatment session?'''<br>Vital signs including: blood pressure, heart rate, and respiratory rate.<br>
What should be monitored during treatment session?: [[Vital Signs|Vital signs]] including: [[Blood Pressure|blood pressure]], [[Heart Rate|heart rate]], and [[Respiratory Rate|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.  
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|hyperthyroidism]])<br><br>
'''Hyperthyroidism and Exercise''' (see [[Hyperthyroidism|hyperthyroidism]])  
 
== Differential Diagnosis  ==
 
Diagnosis of thyroid storm is made based on clinical assessment as it is a medical emergency and treatment can not wait until lab results are provided. The diagnostic criteria discussed in Table 1 above are used to help guide the clinician in diagnosis. Other conditions to differentiate between for thyroid storm include:
 
*Hyperthyroidism
*Graves Disease
*Atrial Fibrillation
*Hypoglycemic Attack
*Sepsis
*CVA
*Sympathomimetic toxicity<br><br>


== Case Reports/ Case Studies  ==
== Case Reports/ Case Studies  ==


1. Intraoperative Thyroid Storm: A Case Report<sup>[6]</sup>
Thyroid Storm during induction of anesthesia http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3506864/ <br>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.  
 
= References  =
http://eds.a.ebscohost.com/ehost/pdfviewer/pdfviewer?sid=be2eb971-e9c0-47be-8fa3-2d63ac084f75%40sessionmgr4005&amp;vid=12&amp;hid=4210 <br>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.<br>
 
2.Thyroid Storm Precipitated by Duodenal Ulcer Perforation<ref name="7">Nutsuda S, Natkashima Y, Horie I, Ando T, Kawakami A. Thyroid Storm Precipitated by Duodenal Ulcer Perforation. Case Reports in Endocrinology.2015.1-3.http://www.ncbi.nlm.nih.gov/pubmed/25838951. (accessed 9 April 2016)</ref>&nbsp;
 
http://eds.a.ebscohost.com/ehost/pdfviewer/pdfviewer?sid=be2eb971-e9c0-47be-8fa3-2d63ac084f75%40sessionmgr4005&amp;vid=12&amp;hid=4210 <br> 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. <br>
 
3. Thyroid Storm during induction of anesthesia<ref name="8" />
 
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3506864/ <br>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. <br><br>
 
== Resources <br>  ==
 
http://thyroidmanager.org<br>http://endocrinediseases.org/<br>http://www.thyroid.org/<br>https://www.nahypothyroidism.org/<br><br>
 
== Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed])  ==
 
see tutorial on [[Adding PubMed Feed|Adding PubMed Feed]]
<div class="researchbox">
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== References  ==
 
see [[Adding References|adding references tutorial]].


<references />  
<references />&nbsp;


[[Category:Bellarmine_Student_Project]]
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Latest revision as of 16:58, 1 March 2022

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[edit | edit source]

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. [1] The mortality associated with thyroid storm is estimated to be 8-25% despite modern advancements in its treatment and supportive measures.[2]

Thyroid storm:

  • Most commonly seen in the context of underlying Graves' disease but can complicate thyrotoxicosis of any aetiology.[3]
  • Accounts for about 1% to 2% of admissions for hyperthyroidism.[2]

Characteristics/Clinical Presentation[edit | edit source]

Signs and symptoms hyperthyroidism

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

Physical examination findings may include high temperature, tachycardia, orbitopathy, goiter, hand tremors, moist and warm skin, hyperreflexia, systolic hypertension, and jaundice.[2]

Etiology[edit | edit source]

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.[3]

Management[edit | edit source]

Throid storm managed in ICU

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.[2]

Physical Therapy Management[edit | edit source]

Clinicians in Intensive Care Unit

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[edit | edit source]

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.

References[edit | edit source]

  1. ↑ Chiha M, Samarasinghe S, Kabaker AS. Thyroid storm: an updated review. Journal of intensive care medicine. 2015 Mar;30(3):131-40.Available: https://pubmed.ncbi.nlm.nih.gov/23920160/ (accessed 23.2.2022)
  2. ↑ 2.0 2.1 2.2 2.3 Pokhrel B, Aiman W, Bhusal K. Thyroid storm. Available: https://www.ncbi.nlm.nih.gov/books/NBK448095/(accessed 23.2.2022)
  3. ↑ 3.0 3.1 Carroll R, Matfin G. Endocrine and metabolic emergencies: thyroid storm. Therapeutic advances in endocrinology and metabolism. 2010 Aug;1(3):139-45. Available:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3475282/ (accessed 23.2.2022)

 

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