THYROID

STORM
Ns. Retno Setyawati, M. Kep., SpKMB
Thyroid Storm
■ Thyroid storm, also referred to as thyrotoxic
crisis, is an acute, life-threatening,
hypermetabolic state induced by
excessive release of thyroid hormones (THs) in
individuals with thyrotoxicosis.
■ Thyroid Storm (TS) or Thyroid Crisis (TC)
usually develops after some specific precipitating
event such as infection, sepsis, trauma,
cerebrovascular accident, or radioactive iodine
therapy, etc
Precipitants of Thyroid Storm

■ Thyroid surgery/surgical storm

■ Nonthyroidal surgery
■ Trauma
■ Vigorous manipulation of the thyroid gland
■ Thyroiditis
■ Burn
■ Myocardial infarct
■ Pulmonary embolism
■ Cerebrovascular incidents
Cont…
■ Medications such as anesthetics, salicylates,
pseudoephedrine, and amiodarone
■ Interferon treatment
■ Radioactive iodine treatment
■ Exposure to iodinated contrast
■ Withdrawal of antithyroid treatment
■ Infections
■ Diabetic ketoacidosis
■ Hypoglycemia
Cont…
■ Acute ingestion of high doses of thyroid hormone
■ Metastatic thyroid cancer
■ Molar pregnancy
■ Emotional stress
■ Intense exercise
Symptoms
■ General symptoms
– Fever
– Profuse sweating
– Poor feeding and weight loss
– Respiratory distress
– Fatigue (more common in older adolescents)
■ GI symptoms
– Nausea and vomiting
– Diarrhea
– Abdominal pain
– Jaundice [12]
Cont…
■ Neurologic symptoms
– Anxiety (more common in older
adolescents)
– Altered behavior
– Seizures, coma
 Physical Examination
■ Fever
– Temperature consistently exceeds 38.5°C.
– Patients may progress to hyperpyrexia.
– Temperature frequently exceeds 41°C.
■ Excessive sweating
■ Cardiovascular signs
– Hypertension with wide pulse pressure
– Hypotension in later stages with shock
– Tachycardia disproportionate to fever
– Signs of high-output heart failure
– Cardiac arrhythmia (Supraventricular arrhythmias are
more common, [eg, atrial flutter and fibrillation], but
ventricular tachycardia may also occur.)
Cont…
■ Neurologic signs
– Agitation and confusion
– Hyperreflexia and transient pyramidal signs
– Tremors, seizures
– Coma
■ Signs of thyrotoxicosis
– Orbital signs
– Goiter
■ Rhabdomyolysis - Rare cases have been reported
following a diagnosis of thyroid storm in adults
LABORATORY STUDIES

a. Usually findings include elevated

triiodothyronine (T3) and thyroxine (T4),
elevated free T4, increased T3 resin uptake,
suppressed TSH, and an elevated 24-hour
iodine uptake. TSH is not suppressed if the
etiology is excess TSH secretion.
b. Hypercalcemia may occur from
thyrotoxicosis
Cont…
d. CBC reveals mild leukocytosis, with a shift to the
left.
e. Liver function tests commonly show nonspecific
abnormalities such as elevated alanine
aminotransferase (ALT), aspartate
aminotransferase (AST), lactate dehydrogenase
(LDH), creatin kinase, alkaline phosphatase, and
serum bilirubin.
f. Blood gases, electrolytes, and urinalysis testing
may be performed to assess and monitor
shortterm management.
 Acute Care Patient Management

Nursing Diagnosis: Decreased cardiac output related

to increased cardiac work secondary to increased
adrenergic activity; Deficient fluid volume secondary
to increased metabolism and diaphoresis.

Outcome Criteria
■ Patient alert and oriented
■ Peripheral pulses palpable
■ Lung clear to auscultation
■ Urine output 30 ml/hr
■ Absence of life-threatening dysrhythmias
Patient Monitoring
■ Continuously monitor ECG for dysrhythmias or
HR ? 140 beats/min that can adversely affect
cardiac output and monitor for ST segment
changes indicative of myocardial ischemia.
■ Continuously monitor oxygen saturation with
pulse oximetry.
■ Continuously monitor pulmonary artery pressure.
■ Monitor fluid volume status; measure urine output
hourly and determine fluid balance every 8 hours.
Patient Assessment
■ Assess cardiovascular status; extra heart
sounds, complaints of orthopnea or
dyspnea on exertion.
■ Assess hydration status because
dehydration can further decrease
circulating volume and compromise
cardiac output.
■ Assess for pressure ulcer development
secondary to hypoperfusion.
SUPPORTIVE CARE OF THYROID
STORM

 The general supportive therapy may include:

1. Fluid balance, Glucose Infusion for nutrition
2. Oxygen
3. Cardio respiratory status
4. Cooling Blanket
5. Acetaminophen (Avoid Aspirin: since this drug will
displace T4 from TBG, resulting in an increase in
FT4. Chlorpromazine (50-100 mg I.M) can be used
to treat agitation and because of its effect in
inhibiting central thermoregulation, hence, it may be
useful in treating hyperpyrexia.
Cont…
6. Fenobarbital. Ini mungkin merupakan obat penenang
yang bermanfaat karena merangsang metabolisme T4
melalui sistem enzim mikrosom hati.
7. Multivitamin.
8. If indicated: antibiotics, digoxin, NG-tube, etc.
9. Treat the underlying condition, if any, that
precipitated thyroid storm and exclude comorbidities
such as diabetic ketoacidosis and adrenal
insufficiency. Infection should be treated with
antibiotics.
10. Rarely, as a life-saving measure, plasmapheresis
(plasma exchange) has been used to treat thyroid
storm in adults.