-Case-
A 38-year-old woman with a history of Graves’ disease arrives at your ED. Her family says she’s been “acting strange” and vomiting for the past few days, and today, she’s confused and restless. On exam, she’s febrile to 101.5F, tachycardic to145, and her blood pressure is 165/95. She’s diaphoretic, tremulous, and clearly agitated.
Diaphoresis, tachycardia, and HTN are all signs of autonomic hyperactivity and should make you pause. Could these signs point to something more dire?
-Evaluation-
Thyroid storm is a rare, life-threatening exacerbation of hyperthyroidism. Patients typically present with a constellation of severe symptoms reflecting widespread organ system involvement:
- Classic findings include fever, tachycardia (often out of proportion to the fever), and altered mental status ranging from agitation to coma
- Other features include systolic hypertension and GI upset (nausea, vomiting, diarrhea)
Precipitating factors like infection, trauma, surgery, or recent radioactive iodine therapy are often seen, so a thorough history is key.
To confirm the diagnosis, use your clinical gestalt rather than relying solely on lab values. TSH will be low and free T4/T3 levels will be elevated, but these findings are also consistent with uncomplicated hyperthyroidism! In other words, labs won’t differentiate storm from a less severe hyperthyroid state.
-Management-
Accelerate your learning with our EM Question Bank Podcast
- Rapid learning
- Interactive questions and answers
- new episodes every week
- Become a valuable supporter
Thyroid storm management can be complex and requires a multi-pronged approach to block hormone synthesis, prevent peripheral effects, and address the underlying trigger.
- Beta blockade:
- Use beta-blockers to control tachycardia and decrease T4 to T3 conversion.
- On any exam, the correct answer is propranolol; clinically, this isn’t always true! In fact, esmolol, metoprolol, diltiazem can be used, too, and some even prefer esmolol due to it’s faster onset of action.
- Block Hormone Production and Release:
- Thionamides are key here! Propylthiouracil (PTU) is preferred over methimazole initially due to its additional ability to block peripheral T4 to T3 conversion.
- Wait about an hour after starting PTU, then give iodine (e.g., potassium iodide) to inhibit further thyroid hormone release.
- Addressing the Underlying Trigger: treat any precipitating infections, manage trauma, or stabilize post-op patients. Also, don’t forget supportive care! IV fluids, cooling measures for hyperthermia, and antiemetics for GI symptoms will make your patient feel a whole lot better while we address the underlying pathology.
-Fast Facts-
- Thyroid storm is often identified with high clinical suspicion; fever, tachycardia, agitation/confusion, and other signs of hyperthyroidism should all clue you into this pathology, especially if your patient has a history of hyperthyroidism
- Precipitating factors include infection, trauma, surgery, or inappropriate use of prescribed antithyroid medications
- Block hormone synthesis with thionamides + iodine and use beta-blockers for symptom control
- The main complications we worry about are heart failure, arrhythmias, multi-organ failure, and death without timely treatment!
Thyroid storm is a ticking time bomb, but early recognition and intervention can make a huge difference. This pathology reminds us to stay vigilant for the subtle signs of hyperthyroid crises and act quickly to prevent these catastrophic outcomes. The storm may be brewing, but you can weather it with the right approach!
Want to read more about this topic? Click ✨here✨to read our in-depth study guide!
Cheers,
Tamir Zitelny, MD