Introduction
Thyroid storm also known as thyrotoxic crisis is a rare but life-threatening condition of hypermetabolic state induced by excessive release of thyroid hormones (THs) in individuals with thyrotoxicosis.
Mortality rate is up to 30% even with treatment.
Causes of death include cardiac failure, arrythmias and hyperthermia
Precipitants of thyroid storm (thyrotoxic crisis) include the following:
- Infections
- Trauma & Surgery
- Stroke
- Diabetic ketoacidosis
- Radio iodine treatment of patients with partially treated or untreated hyperthyroidism
Clinical features of thyroid storm (thyrotoxic crisis)
- Fever
- Diarrhoea
- Vomiting
- Jaundice
- Seizures
- Coma
Complications of thyroid storm (thyrotoxic crisis)
The complications of thyroid storm (thyrotoxic crisis) are:
- Cardiac failure
- Arrythmias
- Hyperthermias
Investigations
- Diagnosis is mainly clinical and laboratory investigations are done to identify possible precipitants-infection.
- Level of thyroid hormones may not be markedly elevated.
- Correlation does not exist between levels of thyroid hormones and thyroid storm.
- FBC may show leucocytosis even in the absence of infection
- Raised bilirubin,
- Alkaline phosphatase
Management
- The management of thyroid storm (thyrotoxic crisis) requires intensive monitoring
- Supportive care
- Identification and treatment of precipitating cause(s)
Treatment objectives
- Reduction in T synthesis/action and
restoration to normal values - Treatment of identified precipitating factors
- Prevention of complications
Drug treatment
Propylthiouracil
Adult: 600 mg loading dose; 200 – 300 mg orally every 6 hours by nasogastric tube or per rectum
Child:
- 5-12 years: Initially 50 mg orally 3 times daily until euthyroid then adjusted as
necessary
- 12 18 years. Initially 100 mg 8 hourly daily administered until euthyroid then adjusted as necessary; higher doses
sometimes required
Saturated Solution of Potassium lodide
(SSKI)
Adult: 5 drops every 6 hours; to be
commenced 1 hour after the first dose of propylthiouracil
Child:
- 1 month -1 year: 0.2 – 0.3 mL orally 8 hourly daily.
- Dilute well with milk and water
Propranolol
Adult: 40-60 mg orally every 4 hours or 2 mg intravenously every 4 hours
Child:
- Neonate, initially 250-500 μg/kg every 6 -8 hours, adjusted according to response
- 1 month – 18 years: initially 250-500 μg/kg every 6 – 8 hours, adjusted according to response; doses up to 1 mg/kg may be required; maximum 40 mg every 8 hours
Dexamethasone
- 2 mg intravenously every 6 hours
Intravenous Chlorpromazine 50-100mg.
- Intramuscular route to treat agitation
Intravenous anti-arrhythmic
- Used if arrhythmia is present; choice of drug depends on arrhythmia type.
Antibiotics
- (if infection is present)
Supportive measures
- Adequate hydration with intravenous fluids and cooling