What is it?
- Sudden severe life threatening exacerbation of hyperthyroidism a/w multiple organ decompensation.
When to suspect?
- known case of hyperthyroidism with FEVER
- recent history of thyroid disease requiring treatment or a precipitating event e.g: sepsis, surgery, iodinated CT contrast.
- Trauma patient with increasing pulse & BP
Why I should know?
- Mortality 20-50% if untreated
What I should avoid?
- aspirin based antipyretics, cause it will release free T4 and T3 from protein bound site.
How they present?
- Fever – 2′ sepsis/ thyroid storm
- Tachycardia out of proportion to temperature
- increase thyrotoxic symptoms: weight loss and tremors
- multi organ dysfunction:
- CNS: confusion, delirium, agitation, stupor, coma
- GI: abdominal pain, diarrhea, vomit, jaundice (liver dysfunction)
- CVS: Systolic hyper/hypotension, heart failure, AFI (atrial fibrillation), AF (atrial flutter), high output cardiac failure – (term is a misnomer because the heart in these conditions is normal, capable of generating very high cardiac output. The underlying problem in high output failure is a decrease in the systemic vascular resistance that threatens the arterial blood pressure and causes activation of neurohormones, resulting in an increase in salt and water retention by the kidney)
- Volume depletion 2′ fever, increased metabolism, diarrhea.
- goitre, lid lag/ retraction & myopathy.
- RP, calcium
- TSH, free T4
- CXR – heart failure/ infection
- UFEME – rule out infection
- Red zone
- HFMO2 (thyrotoxicosis increase metabolism and oxygen consumption)
- BP/PR 10-15 min
- 2 large bore branulla, IV drip. correct volume depletion cautiously to avoid precipitating heart failure. correct electrolytes imbalance (hypercalcemia, hyperglycemia).
- treat precipitating factor: e.g. sepsis, MI
- T. PCM, tepid
2) Block the adrenergic Beta receptor
- Beta blocker: crucial even in the presence of high output cardiac failure.
- IV Esmolol – ultra short acting, test dose 250 ug/kg followed by 50 ug/kg/min or,
- IV Propanolol 1 mg every 5 minutes until severe tachycardia is controlled. then T. Propanolol 60 mg every 4 hours or 80 mg TDS.
3) Block T4 peripheral conversion
- IV Hydrocortisone: 100 mg TDS, blocked conversion free T4 to T3
4) Block T4 & T3 synthesis
- PTU(Thioamides): blocks iodination and conversion of T4 to T3.
- 400-600 mg STAT orally/ Ryles tube, then 200-300 mg every 4 hours.
- Per rectal can be given by dilute in fleet enema
5) Block T4 & T3 Release
- Lugol’s Iodine: inhibit release of thyroid hormone
- 1-2 hours post -PTU
- 5 drops per oral or via RT TDS.
- if NBM: IV sodium iodide 1 g/500 ml saline BD.
6) Treat Precipitating cause.