Thyroid Storm

04/12/23 THYROID STORM 1

Thyroid storm


Anatomy of the thyroid glandAnatomy of the thyroid gland • The The thyroidthyroid is one of is one of the largest endocrinethe largest endocrine

glandgland in the body in the body• The thyroid gland is located in The thyroid gland is located in the front of the necthe front of the nec

k, below the larynxk, below the larynx (voice box). The small, two-inc (voice box). The small, two-inch gland consists of two lobes, one on each side of h gland consists of two lobes, one on each side of the windpipe, connected by tissue called the isthmthe windpipe, connected by tissue called the isthmus.us.

• The thyroid tissue is made up of two types of cells: The thyroid tissue is made up of two types of cells: follicular cells and parafollicular cells. Most of the tfollicular cells and parafollicular cells. Most of the thyroid tissue consists of the follicular cells, which hyroid tissue consists of the follicular cells, which secrete secrete iodine-containing hormones called thyroxiiodine-containing hormones called thyroxine (T4) and triiodothyronine (T3).ne (T4) and triiodothyronine (T3). The parafollicula The parafollicular cells r cells secrete the hormone calcitoninsecrete the hormone calcitonin. The thyroid . The thyroid needs iodine to produce the hormones.needs iodine to produce the hormones.


Anatomy of thyroid glandAnatomy of thyroid gland


Functions& Physiology of the Functions& Physiology of the thyroid glandthyroid gland

• The thyroid plays an important role in The thyroid plays an important role in regulating regulating the body's metabolism and calcium balancethe body's metabolism and calcium balance. The . The T4 and T3 hormones stimulate every tissue in T4 and T3 hormones stimulate every tissue in the body to the body to produce proteins and increase the produce proteins and increase the amount of oxygen used by cells.amount of oxygen used by cells. The harder the The harder the cells work, the harder the organs work. The cells work, the harder the organs work. The calcitonin hormone works together with the calcitonin hormone works together with the parathyroid hormone to regulate calcium levels parathyroid hormone to regulate calcium levels in the body.in the body.

• Levels of hormones secreted by the thyroid are Levels of hormones secreted by the thyroid are controlled by the pituitary gland'scontrolled by the pituitary gland's thyroidthyroid-stimulating hormone, which in turn is stimulating hormone, which in turn is controlled controlled by the hypothalamus.by the hypothalamus.


Physiology of thyroid Physiology of thyroid hormoneshormones


Thyroid diseaseDefinitionDefinition

• HyperthyroidismHyperthyroidism

– Overproduction of hormone from the thyroid gland

• Thyrotoxicosis

– Any cause of excessive thyroid hormone concentration

• Graves' diseaseGraves' disease

– AAutoimmune diseaseutoimmune disease andand aa metabolic imbalance metabolic imbalance resulting from resulting from overproduction of thyroid hormonesoverproduction of thyroid hormones

• Euthyroidism

– Normal functioning of the thyroid gland , normal , normal serum levels of thyroid hormoneserum levels of thyroid hormone


Thyroid storm or Thyroid crisis

DefinitionDefinition• Exacerbation of hyperthyroidismExacerbation of hyperthyroidism• Acute, life-threatening, hypermetabolic stateAcute, life-threatening, hypermetabolic state• Thyroid storm may be the initial presentation of Thyroid storm may be the initial presentation of

thyrotoxicosisthyrotoxicosis• Less than 10% of hospitalized thyrotoxicosisLess than 10% of hospitalized thyrotoxicosis• Mortality: 20-30%Mortality: 20-30%


EtiologyEtiology• Graves’ disease (most common)• Solitary toxic adenoma or toxic multinodular

goiter• Rare cause

– hypersecretory thyroid carcinoma– thyrotropin-secreting pituitary adenoma– struma ovarii/teratoma– human chorionic gonadotropia–secreting

hydatidiform mole.• Other causes

– interferon alpha – interleukin-2–induced thyrotoxicosis


Precipitating event• Systemic insults

– Surgery, trauma, myocardial infarction, pulmonary thromboembolism, DKA, severe infection

• Discontinuation of antithyroid drugs• Excessive iodine (eg, radiocontrast dyes,

amiodarone)• Radioiodine therapy• Pseudoephedrine and salicylate use


Thyroid StormThyroid Storm- diagnosis- diagnosis

• A score of A score of 45 or more 45 or more is highly suggestive of is highly suggestive of thyroid stormthyroid storm; a score ; a score of 25 to 44 supports of 25 to 44 supports the diagnosis; and a the diagnosis; and a score below 25 score below 25 makes thyroid storm makes thyroid storm unlikely.unlikely.

40ºC

37.2 – 37.7ºC


Clinical presentation


Symptoms of Thyroid StormSymptoms of Thyroid Storm• Increased body temperature Increased body temperature

• Tachycardia (rapid heart rate)Tachycardia (rapid heart rate)

• Nausea/vomitingNausea/vomiting

• Frequent loose bowel movements Frequent loose bowel movements

• Heart palpitations Heart palpitations

• Heart failureHeart failure

• Pulmonary edema Pulmonary edema

• ConfusionConfusion

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LABLAB free T4 and free T3TSHTSH• Hyperglycemia, elevated alkaline

phosphatase, leukocytosis, Mild hypercalcemia,and elevated liver enzymes

• Cortisol Cortisol (normal level → adrenal (normal level → adrenal insufficiency)insufficiency)


Storm TreatmentsStorm TreatmentsTreatments directed at thyroid gland Treatments directed at thyroid gland

and hormonesand hormones

• Inhibition of new hormone synthesis Inhibition of new hormone synthesis with with Thioamide drugs such as PTU Thioamide drugs such as PTU and methimazoleand methimazole

• Inhibition of hormone release with Inhibition of hormone release with Iodine & Iodine & potassium iodide (Lugol’s potassium iodide (Lugol’s solution) & Lithium carbonatesolution) & Lithium carbonate


Storm TreatmentsStorm TreatmentsTreatments directed at preventing Treatments directed at preventing

hormone’s affects on the bodyhormone’s affects on the body

• Polythiouracil (PTU)Polythiouracil (PTU)

• CorticosteroidsCorticosteroids

• Beta blockers (most importantly Beta blockers (most importantly Propanolol)Propanolol)

• AmiodaroneAmiodarone

• PlasmapheresisPlasmapheresis


Storm TreatmentsStorm TreatmentsTreatments directed at maintaining Treatments directed at maintaining

homeostasishomeostasis

• Hyperthermia: acetaminophen, cooling Hyperthermia: acetaminophen, cooling blanketsblankets

• Fluid and electrolyte testing/replacementFluid and electrolyte testing/replacement

• GlucoseGlucose

• VasopressorsVasopressors

• Digoxin & diuretics if appropriateDigoxin & diuretics if appropriate


Treatment SummaryTreatment SummaryOverall Goal: Reduce circulation thyroid levels and Overall Goal: Reduce circulation thyroid levels and

control symptomcontrol symptom

– Beta blockers:Beta blockers: decreases adrenergic decreases adrenergic hyperactivity (sympathetic outflow)hyperactivity (sympathetic outflow)

– PTU (large amounts):PTU (large amounts): prevents synthesis of prevents synthesis of the hormonethe hormone

– Glucocorticoids:Glucocorticoids: inhibit hormone inhibit hormone production and decrease peripheral production and decrease peripheral conversion from T4 to T3. conversion from T4 to T3.

– Sodium iodide solution (Lugol’s solution):Sodium iodide solution (Lugol’s solution): High levels of iodide will initially suppress High levels of iodide will initially suppress release of thyroid hormonerelease of thyroid hormone

– Treat cardiac symptoms, fever and Treat cardiac symptoms, fever and hypertensionhypertension

Health & Medicine

Thyroid Storm