Thyroid Storm

1. 12/01/09 THYROID STORM 1
Thyroid storm

2. 12/01/09 THYROID STORM 2
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 the front of the
neck, below the larynxneck, below the larynx (voice box). The small, two (voice box). The small, two
-inch gland consists of two lobes, one on each sid-inch gland consists of two lobes, one on each sid
e of the windpipe, connected by tissue called the ie of the windpipe, connected by tissue called the i
sthmus.sthmus.
•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 follicular cells and parafollicular cells. Most of the
thyroid tissue consists of the follicular cells, which thyroid tissue consists of the follicular cells, which
secrete secrete iodine-containing hormones called thyroxiiodine-containing hormones called thyroxi
ne (T4) and triiodothyronine (T3).ne (T4) and triiodothyronine (T3). The parafollicula The parafollicula
r 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.

3. 12/01/09 THYROID STORM 3
Anatomy of thyroid glandAnatomy of thyroid gland

4. 12/01/09 THYROID STORM 4
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 thyroid- thyroid-
stimulating hormone, which in turn is stimulating hormone, which in turn is controlled controlled
by the hypothalamus.by the hypothalamus.

5. 12/01/09 THYROID STORM 5
Physiology of thyroid Physiology of thyroid
hormoneshormones

6. 12/01/09 THYROID STORM 6
Thyroid disease
DefinitionDefinition
•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

7. 12/01/09 THYROID STORM 7
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%

8. 12/01/09 THYROID STORM 8
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

9. 12/01/09 THYROID STORM 9
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

10. 12/01/09 THYROID STORM 10
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

11. 12/01/09 THYROID STORM 11
Clinical presentation

12. 12/01/09 THYROID STORM 12
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
•
•
•
•
•
•
•
•

13. 12/01/09 THYROID STORM 13
LABLAB
"­­ free T4 and free T3
"¯¯TSHTSH
•Hyperglycemia, elevated alkaline
phosphatase, leukocytosis, Mild
hypercalcemia,and elevated liver
enzymes
•Cortisol Cortisol ­­ (normal level → adrenal (normal level → adrenal
insufficiency)insufficiency)

14. 12/01/09 THYROID STORM 14
Storm TreatmentsStorm Treatments
Treatments 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

15. 12/01/09 THYROID STORM 15
Storm TreatmentsStorm Treatments
Treatments 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

16. 12/01/09 THYROID STORM 16
Storm TreatmentsStorm Treatments
Treatments 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

17. 12/01/09 THYROID STORM 17
Treatment SummaryTreatment Summary
Overall 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