Is this hyperthyroid storm? If so, now what?

Hyperthyroid storm is rare.

Clinical clues to diagnosis include:

  • history of hyperthyroidism, most commonly Graves' disease

  • new physiologic stress to precipitate thyroid storm

  • extreme signs and symptoms of adrenergic hyperactivity

  • opthalmopathy (exophthalmos, lid lag) if history of Graves'

  • altered mental status

  • proximal myopathy


Diagnostic tests:

  • low TSH with elevated FT4 or Ft3 is diagnostic


Treatment:

  • If clinical suspicion is high, treat immediately

  • block synthesis: propylthiouracil (PTU), this is generally favored over methimazole because it also inhibits peripheral conversion of T4 --> T3

  • block hormone release: iodine (Lugol's iodine solution). PTU should be given 1 hour prior to this to prevent organification of the iodine. Don''t give to patients with iodine-induced hyperthyroidism. Lithium, which has more side affects and is difficult to dose, can be used as an alternative.

  • prevent peripheral hormone conversion: dexamethasone

  • block peripheral adrenergic blockade: propranolol

  • provide supportive care: acetaminophen, ice packs, cooling blankets, treat underlying precipitant, hydrocortisone for potential relative adrenal insufficiency (if given, can exchange for dexamethasone)


Source

Sternlicht, J. Morgan, J. "Thyroid and Adrenal Disorders." Marx: Rosen's Emergency Medicine: Concepts and Clinical Practice, 6th ed. Mosby. 2006
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