Sie sind auf Seite 1von 15

Thyroid, Thyrotoxic Storm Following Thyroidectomy: [Print] - eMedici... http://emedicine.medscape.

com/article/850924-print

emedicine.medscape.com

eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Head & Neck Surgery

Nafisa K Kuwajerwala, MD, Staff Surgeon, Breast Oncology, William Beaumont Hospital
Gunateet Goswami, MD, Consulting Staff, Internal Medicine Associates, Mount Clemens, Michigan; Consulting Staff, Department of Cardiology, Henry
Ford Hospital; Thabet Abbarah, MD, FACS, Consulting Staff, Department of Otolaryngology, North Oakland Medical Centers; Venkata Subramanian
Kanthimathinathan, MD, Staff Physician, Department of General Surgery, Loma Linda University Medical Center; Pankaj Chaturvedi, MBBS, MS,
Associate Professor, Head and Neck Surgery, Department of Surgical Oncology, Tata Memorial Hospital, India
Updated: Sep 2, 2009

Introduction

Background
Thyroid storm is a clinical manifestation of an extreme hyperthyroid state that results in significant morbidity or disability or even death.
Previously, thyroid storm was a common complication of toxic goiter surgery during intraoperative and postoperative stages.
Preoperative control of the thyrotoxic state and use of radioiodine ablation has greatly reduced this phenomenon. Today, thyroid storm
more commonly is seen in a thyrotoxic patient with intercurrent illness or surgical emergency. Early recognition and prompt intervention
are necessary to prevail in management of this phenomenon.

Frequency
International

Presently, incidence is less than 10% among patients hospitalized for thyrotoxicosis.

Mortality/Morbidity

Thyroid storm, considered a fulminating state, is fatal when untreated.

Although methods of diagnosis and management have improved considerably, reported mortality still is 20-30%.

Although it can develop in toxic adenoma or multinodular toxic goiter, thyroid storm is more commonly seen in toxicity secondary
to Graves disease.

1 of 15 05.09.2009 00:02
Thyroid, Thyrotoxic Storm Following Thyroidectomy: [Print] - eMedici... http://emedicine.medscape.com/article/850924-print

Pathophysiologic mechanisms of Graves disease relating thyroid-stimulating immunoglobulins to


hyperthyroidism and ophthalmopathy. T4 is levothyroxine. T3 is triiodothyronine.

Sex
Age and sex predilection depends on the etiology of thyrotoxicity. Graves disease more frequently develops in females (ie, male-to-
female ratio ranges from 1:7 to 1:10); multinodular goiter more often manifests in the elderly population.

Clinical

History
Clinical features form the hallmark in diagnosing thyroid storm. Most patients have goiter, and many of those with Graves disease have
concurrent ophthalmopathy. Frequently, a past history of thyroid disease that has been partially treated exists.

Physical

An accentuation of signs and symptoms is seen in uncomplicated thyrotoxicosis. The point of transition from uncomplicated
thyrotoxicosis to thyroid storm is difficult to ascertain. Very few criteria define the change. However, certain clinical features (eg,
high-grade fever, mental obtundation, decompensation of one or more organ systems secondary to the severe state of
hypermetabolism) herald its onset.

The table below presents some changes in the symptoms and signs of thyroid storm when compared with uncomplicated
thyrotoxicosis. Importantly, some findings of thyroid storm (eg, atrial dysrhythmia) may also prevail in uncomplicated

2 of 15 05.09.2009 00:02
Thyroid, Thyrotoxic Storm Following Thyroidectomy: [Print] - eMedici... http://emedicine.medscape.com/article/850924-print

thyrotoxicosis. Therefore, the table represents only guidelines, not specific criteria to define thyroid storm.

Uncomplicated Thyrotoxicosis Thyroid Storm


o
1. Heat intolerance, diaphoresis 1. Hyperpyrexia, temperature in excess of 106 C,
dehydration

2. Sinus tachycardia, heart rate 100-140 2. Heart rate faster than 140 beats/min, hypotension,
atrial dysrhythmias, congestive heart failure

3. Diarrhea, increased appetite with loss of weight 3. Nausea, vomiting, severe diarrhea, abdominal pain,
hepatocellular dysfunction-jaundice

4. Anxiety, restlessness 4. Confusion, agitation, delirium, frank psychosis, seizures,


stupor or coma

Certain unusual presentations include chest pain, acute abdomen, status epilepticus, stroke, acute renal failure due to
rhabdomyolysis, and apathetic thyroidism. Lahey first described apathetic thyroidism (ie, masked hyperthyroidism) 60 years
ago.1 Apathetic thyroidism more frequently was seen in elderly patients but since has been described in all ages. Patients in this
variant group present without goiter, ophthalmopathy, or prominent symptoms of hyperthyroidism. These patients have a low
pulse rate and a propensity to develop thyroid storm due to delay in diagnosis.

Causes
A precipitating factor usually is found with thyroid storm. Presently, the most common cause of thyroid storm is intercurrent illness or
infection (ie, medical storm).

Some causes that rapidly increase the thyroid hormone levels include the following:
Surgery, thyroidal or nonthyroidal
Radioiodine therapy
Withdrawal of antithyroid drug therapy
Vigorous thyroid palpation
Iodinated contrast dye
Thyroid hormone ingestion

Other common precipitants include the following:


Infection
Emotional stress
Tooth extraction
Diabetic ketoacidosis
Hypoglycemia
Trauma
Bowel infarction
Parturition
Toxemia of pregnancy
Pulmonary embolism
Cerebrovascular accident
Gestational trophoblastic disease

Differential Diagnoses

Other Problems to Be Considered


Postoperative complications (eg, sepsis, hemorrhage, septicemia, transfusion drug reactions) mimic the thyrotoxic state. Previous
history of hyperthyroidism, precipitating factors, increased T3 and T4 levels, and decreased thyroid stimulating hormone (TSH) levels
help to establish the diagnosis of thyroid storm.

Workup

Laboratory Studies

3 of 15 05.09.2009 00:02
Thyroid, Thyrotoxic Storm Following Thyroidectomy: [Print] - eMedici... http://emedicine.medscape.com/article/850924-print

Presently, no specific diagnostic criteria to establish the diagnosis of thyroid storm exist.

Burch and Wartofsky have constructed an excellent clinical diagnostic point scale to facilitate a semiquantitative distinction
between uncomplicated thyrotoxicosis, impending storm, and established thyroid storm.2 Laboratory findings in thyroid storm
are consistent with those of thyrotoxicosis and include the following:
Elevated T3 and T4 levels
Elevated T3 uptake
Suppressed TSH levels
Elevated 24-hour radioiodine uptake

Elevated T4 and decreased TSH are the only abnormal findings needed for conformation of thyrotoxicosis. Treatment should
not be withheld for any laboratory confirmation of hyperthyroidism when thyroid storm is suspected clinically. A 2-hour
radioiodine uptake is advisable if thyroid storm is suspected and no past history of hyperthyroidism exists.

Other abnormal laboratory values that point toward decompensation of homeostasis include the following:
Increased BUN and creatinine kinase
Electrolyte imbalance from dehydration, anemia, thrombocytopenia, and leukocytosis
Hepatocellular dysfunction as shown by elevated levels of transaminases, lactate dehydrogenase, alkaline phosphatase,
and bilirubin
Elevated calcium levels
Hyperglycemia

Treatment

Medical Care
Management of thyroid storm is a multi-step process. Blocking the synthesis, secretion, and peripheral action of the thyroid hormone is
the ideal therapy. Aggressive supportive therapy then is used to stabilize homeostasis and reverse multiorgan decompensation.
Additional measures are taken to identify and treat the precipitating factor, followed by definitive treatment to avoid recurrence. Thyroid
storm is a fulminating crisis that demands an intensive level of care, continuous monitoring, and vigilance.

Blocking thyroid hormone synthesis


Antithyroid compounds propylthiouracil (PTU) and methimazole (MMI) are used to block the synthesis of the thyroid
hormone.
PTU also blocks peripheral conversion of T4 to T3 and hence is preferred in thyroid storm over MMI. MMI is the common
agent used in hyperthyroidism.
PTU and MMI block the incorporation of iodine into thyroglobulin within 1 hour of ingestion.
A history of hepatotoxicity or agranulocytosis from previous thioamide therapy precludes use of PTU and MMI.
The US Food and Drug Administration (FDA) has identified 32 cases (22 adult and 10 pediatric) of serious liver injury
associated with propylthiouracil (PTU). Of the adults, 12 deaths and 5 liver transplants occurred, and among the pediatric
patients, 1 death and 6 liver transplants occurred. PTU is indicated for hyperthyroidism due to Graves disease. These
reports suggest an increased risk for liver toxicity with PTU compared with methimazole. Serious liver injury has been
identified with methimazole in 5 cases (3 resulting in death). PTU is considered as second-line drug therapy, except in
patients who are allergic or intolerant to methimazole, or for women who are in the first trimester of pregnancy. Rare
cases of embryopathy, including aplasia cutis, have been reported with methimazole during pregnancy. The FDA
recommends the following criteria be considered for prescribing PTU. For more information see the FDA Safety Alert.
Reserve PTU use during first trimester of pregnancy, or in patients who are allergic to or intolerant of
methimazole.
Closely monitor PTU therapy for signs and symptoms of liver injury, especially during the first 6 months after
initiation of therapy.
For suspected liver injury, promptly discontinue PTU therapy and evaluate for evidence of liver injury and provide
supportive care.
PTU should not be used in pediatric patients unless the patient is allergic to or intolerant of methimazole, and no
other treatment options are available.
Counsel patients to promptly contact their health care provider for the following signs or symptoms: fatigue,
weakness, vague abdominal pain, loss of appetite, itching, easy bruising, or yellowing of the eyes or skin.

Blocking thyroid hormone secretion

4 of 15 05.09.2009 00:02
Thyroid, Thyrotoxic Storm Following Thyroidectomy: [Print] - eMedici... http://emedicine.medscape.com/article/850924-print

After initiation of antithyroid therapy, hormone release can be inhibited by large doses of iodine, which reduce thyroidal
iodine uptake. Lugol solution or saturated solution of potassium iodide can be used.
Iodine therapy should be administered after approximately 1 hour following administration of PTU or MMI; iodine used
alone helps to increase thyroid hormone stores and may increase the thyrotoxic state.
The iodinated x-ray contrast agent, sodium ipodate, can be administered instead of iodine and also inhibits peripheral
conversion of T4 to T3. Potassium iodide (KI) decreases thyroidal blood flow and hence is used preoperatively in
thyrotoxicosis.
Patients intolerant to iodine can be treated with lithium, which also impairs thyroid hormone release. Patients unable to
take PTU or MMI also can be treated with lithium, as use of iodine alone is debatable. Unlike iodine, lithium is not subject
to the escape phenomenon; lithium blocks the release of thyroid hormone throughout its administration.
Plasmapheresis, plasma exchange, peritoneal dialysis exchange transfusion, and charcoal plasma perfusion are other
techniques used to remove excess circulating hormone. Presently, these techniques are reserved for patients who do
not respond to the initial line of management.
The intravenous preparation of sodium iodide (given as 1 g slow infusion q8-12h) has been taken off of the market.

Blocking peripheral action of thyroid hormone


Propranolol is the drug of choice to counter peripheral action of thyroid hormone. Propranolol blocks beta-adrenergic
receptors and prevents conversion of T4 to T3. It produces dramatic improvement in clinical status and greatly
ameliorates symptoms.
Propranolol produces the desired clinical response in thyroid storm only after large doses.
Intravenous administration of propranolol requires continuous monitoring of cardiac rhythm.
Presently, esmolol is the ultra-short-acting beta-blocking agent used successfully in thyrotoxicosis and thyroid storm.
Noncardioselective beta-blockers (eg, propranolol, esmolol) cannot be used in patients with congestive cardiac failure,
bronchospasm, or history of asthma. Guanethidine or reserpine can be used instead in these cases.
Successful treatment with reserpine in cases of thyroid storm resistant to large doses of propranolol has been
documented. However, guanethidine and reserpine cannot be used in the presence of cardiovascular collapse or shock.

Supportive measures
Aggressive fluid and electrolyte therapy is needed for dehydration and hypotension. This excessive hypermetabolic
state, with increased intestinal transit and tachypnea, leads to immense fluid loss. Fluid requirements may increase to
3-5 L/day. Therefore, invasive monitoring is advisable in elderly patients and in those with congestive cardiac failure.
Pressor agents can be used when hypotension persists following adequate fluid replacement.
Add glucose to IV fluids for nutritional support.
Multivitamins, especially vitamin B-1, are added to prevent Wernicke encephalopathy.
Hyperthermia is treated through central cooling and peripheral heat dissipation.
Acetaminophen is the drug of choice, as aspirin may displace thyroid hormone from binding sites and increase severity
of thyroid storm.
Cooling blankets, ice packs, and alcohol sponges encourage dissipation of heat. Use of a cooled humidified oxygen tent
is advised.
Use of glucocorticoids in thyroid storm is associated with improved survival rates. Initially, glucocorticoids were used to
treat potential relative insufficiency due to accelerated production and degradation owing to the hypermetabolic state.
However, the patient may have type 2 autoimmune deficiency, in which Graves disease coexists with absolute adrenal
insufficiency.
Glucocorticoids reduce iodine uptake and antibody titers of thyroid-stimulating antibodies with stabilization of the vascular
bed. In addition, dexamethasone and hydrocortisone have an inhibitory effect on conversion of T4 to T3. Therefore, a
stress dose of glucocorticoid (eg, hydrocortisone, dexamethasone) now is routine.
Cardiac decompensation, although seen more frequently in elderly patients, may appear in younger patients and in
patients without underlying cardiac disease.
Digitalization is required to control the ventricular rate in patients with atrial fibrillation.
Anticoagulation drugs may be needed for atrial fibrillation and can be administered in the absence of contraindications.3
Digoxin may be used in larger doses than those normally used in other conditions. Closely monitor digoxin levels to
prevent toxicity. As the patient improves, reduce digoxin dose.
Congestive cardiac failure is seen as a result of impaired myocardial contractility and may require Swan-Ganz catheter
monitoring.

5 of 15 05.09.2009 00:02
Thyroid, Thyrotoxic Storm Following Thyroidectomy: [Print] - eMedici... http://emedicine.medscape.com/article/850924-print

Medication
The goals of pharmacotherapy are to reduce morbidity and to prevent complications.

Antithyroid agents
These agents block thyroid hormone synthesis.

Propylthiouracil (PTU)

Thiourea agent that blocks production of thyroid hormones. In addition, inhibits peripheral deiodination of T4 to T3. Preferred over MMI
in thyroid storm.

Dosing

Adult

Not first-line agent


600-1000 mg PO/NT/PR followed by 1200-1500 mg PO/NT/PR qd or 200-250 mg q4h
(No parental preparations available)

Pediatric

Not established

Interactions

PTU has anti–vitamin K activity; may potentiate activity of oral anticoagulants

Contraindications

Documented hypersensitivity; history of hepatotoxicity or agranulocytosis from previous thioamide therapy; pediatric patients (unless
allergic or intolerant to methimazole and no other treatment is an option)

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Monitor PT during therapy; may cause hypoprothrombinemia and bleeding; agranulocytosis may develop, monitor patients for
symptoms (eg, sore throat, fever, bleeding, bruising, malaise, stomatitis) and, if suspected, discontinue drug immediately; once
symptoms of hyperthyroidism have resolved, lower maintenance dose of PTU if serum TSH levels are elevated; risk of serious liver
injury, including liver failure and death, has been reported in adults and children by the FDA (carefully consider drug therapy, and if PTU
initiated, monitor for symptoms and signs of liver injury, especially during first 6 mo of therapy)

Methimazole (Tapazole)

Active moiety of parent compound carbimazole. Blocks incorporation of iodine into thyroglobulin within 1 h of ingestion.
Methimazole was initially thought to be associated with neonatal aplasia cutis (ie, defect in the neonatal scalp) and was thought to be
more likely to cross the placenta than PTU. However, recent studies by Wing et al concluded that PTU and MMI are equally effective
and safe in the treatment of hyperthyroidism in pregnancy.

Dosing

Adult

120 mg PO/NT/PR in divided doses of 20 mg q4h

Pediatric

Not established

Interactions

Inhibits vitamin K activity and may potentiate activity of oral anticoagulants; toxicity increased with coadministration of lithium and
potassium iodide

Contraindications

6 of 15 05.09.2009 00:02
Thyroid, Thyrotoxic Storm Following Thyroidectomy: [Print] - eMedici... http://emedicine.medscape.com/article/850924-print

Documented hypersensitivity; history of hepatotoxicity or agranulocytosis from previous thioamide therapy.

Precautions

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Monitor prothrombin time during therapy; agranulocytosis may develop (monitor patients for symptoms [eg, sore throat, fever, bleeding,
bruising, malaise, stomatitis] and, if suspected, discontinue drug immediately; may cause hypoprothrombinemia and bleeding; once
symptoms of hyperthyroidism have resolved, the presence of elevated serum TSH suggests that a lower maintenance dose of
methimazole should be used

Lithium (Eskalith, Lithotabs)

Used in patients intolerant to iodine; impairs thyroid hormone release.

Dosing

Adult

300 mg PO q6h; adjust dose as necessary to maintain level at approximately 1 mEq/L

Pediatric

Not established

Interactions

Lithium increases toxicity of thiazide diuretics, haloperidol, phenothiazines, neuromuscular blockers carbamazepine, fluoxetine, and
ACE inhibitors

Contraindications

Documented hypersensitivity; severe cardiovascular disease

Precautions

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Lithium toxicity is closely related to serum levels and can develop at therapeutic doses; serum lithium determinations are required to
monitor therapy

Potassium Iodide; Lugol solution (Thyro-Block, Pima)

Inhibits thyroid hormone secretion. Contains 8 mg of iodide per drop. May be mixed with juice or water for intake.
Iodide treatment is reserved for the treatment of thyroid storm. It is also used for 10-14 d prior to surgical procedure, including
thyroidectomy. Can be used with Graves thyrotoxicosis but exacerbates thyrotoxicosis from toxic multinodular goiter and toxic
adenoma.

Dosing

Adult

Lugol solution: 30 gtt/d PO/NT in 4 divided doses


Saturated solution of potassium iodide: 5 gtt PO/NT q6h

Pediatric

Not established

Interactions

Increases lithium toxicity by inducing additive hypothyroid effects

Contraindications

7 of 15 05.09.2009 00:02
Thyroid, Thyrotoxic Storm Following Thyroidectomy: [Print] - eMedici... http://emedicine.medscape.com/article/850924-print

Documented hypersensitivity; pulmonary edema; bronchitis; tuberculosis; hyperkalemia

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

When used alone, iodine helps increase thyroid hormone stores and may increase the thyrotoxic state
Because iodine crosses the placenta, diagnosis or treatment with radioactive iodine (I131) is contraindicated in pregnancy
Nonradioactive iodide prevents release of T3/T4 from thyroglobulin and is used for treatment of hyperthyroidism in women who are not
pregnant
Infants born to mothers treated with prolonged courses of iodide appear to be at increased risk for goiter; therefore, iodide treatment
of women who are pregnant is indicated only in acute circumstances (eg, thyroid storm, immediately before surgical thyroidectomy)
Caution in renal failure and GI obstruction

Sodium ipodate (Oragrafin)

One of the most effective inhibitors of deiodinase, which converts T4 to the more biologically active T3. Reduction in conversion of T4
to T3 can greatly reduce T3 levels and thyrotoxic symptoms.

Dosing

Adult

0.5-3 g/d PO

Pediatric

Not established

Interactions

Coadministration with lithium may result in hypothyroid effects

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Risk of hypotension increases with increased dose; anuria may develop if agents are administered to patients with combined hepatic
and renal disease or severe renal impairment; prolonged iodine storage in tissues may lead to rebound thyrotoxicosis with potential to
cause ethionamide resistance

Glucocorticoids
These agents reduce iodine uptake and antibody titers of thyroid-stimulating antibodies with stabilization of the vascular bed.

Dexamethasone (Decadron, Dexone)

Has many pharmacologic benefits but significant adverse effects. Stabilizes cell and lysosomal membranes, increases surfactant
synthesis, increases serum vitamin A concentration, and inhibits prostaglandin and proinflammatory cytokines (eg, TNF-alpha, IL-6,
IL-2, IFN-gamma). The inhibition of chemotactic factors and factors that increase capillary permeability inhibits recruitment of
inflammatory cells into affected areas. Suppresses lymphocyte proliferation through direct cytolysis and inhibits mitosis. Breaks down
granulocyte aggregates and improves pulmonary microcirculation. Has inhibitory effect on conversion of T4 to T3.
Adverse effects include hyperglycemia, hypertension, weight loss, GI bleeding or perforation synthesis, cerebral palsy, adrenal
suppression, and death. Most of the adverse effects of corticosteroids are dose dependent or duration dependent.
Readily absorbed via the GI tract and metabolized in the liver. Inactive metabolites are excreted via the kidneys. Lacks salt-retaining
property of hydrocortisone.
Patients can be switched from an IV to PO regimen in a 1:1 ratio.

8 of 15 05.09.2009 00:02
Thyroid, Thyrotoxic Storm Following Thyroidectomy: [Print] - eMedici... http://emedicine.medscape.com/article/850924-print

Dosing

Adult

2 mg IV q6h

Pediatric

Not established

Interactions

Effects decrease with coadministration of barbiturates, phenytoin, and rifampin; dexamethasone decreases effect of salicylates and
vaccines used for immunization

Contraindications

Documented hypersensitivity; active bacterial or fungal infection

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Increases risk of multiple complications, including severe infections; monitor adrenal insufficiency when tapering drug; abrupt
discontinuation of glucocorticoids may cause adrenal crisis; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease,
hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections are possible complications of
glucocorticoid use

Hydrocortisone (Cortef, Solu-Cortef)

Elicits anti-inflammatory properties and causes profound and varied metabolic effects. Modifies the body's immune response to
diverse stimuli.

Dosing

Adult

100 mg IV q8h

Pediatric

Not established

Interactions

Corticosteroid clearance may decrease with estrogens; may increase digitalis toxicity secondary to hypokalemia

Contraindications

Documented hypersensitivity; viral, fungal, or tubercular skin infections

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in hyperthyroidism, osteoporosis, peptic ulcer, cirrhosis, nonspecific ulcerative colitis, diabetes, and myasthenia gravis

Analgesics
Pain control is essential to quality patient care. Analgesics ensure patient comfort, promote pulmonary toilet, and have sedating
properties.

Acetaminophen (Feverall, Panadol)

Inhibits action of endogenous pyrogens on heat-regulating centers; reduces fever by a direct action on the hypothalamic
heat-regulating centers, which, in turn, increases the dissipation of body heat via sweating and vasodilation.

9 of 15 05.09.2009 00:02
Thyroid, Thyrotoxic Storm Following Thyroidectomy: [Print] - eMedici... http://emedicine.medscape.com/article/850924-print

Dosing

Adult

650 mg PO q4h

Pediatric

<12 years: 10-15 mg/kg/dose PO q4-6h prn; not to exceed 2.6 g/d
>12 years: 325-650 mg PO q4h; not to exceed 4 g/d

Interactions

Rifampin can reduce analgesic effects of acetaminophen; coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid
may increase hepatotoxicity

Contraindications

Documented hypersensitivity; known G-6-PD deficiency

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Hepatotoxicity possible in persons with long-standing alcoholism following various dose levels; severe or recurrent pain or high or
continued fever may indicate a serious illness; APAP is contained in many OTC products, and combined use with these products may
result in cumulative APAP doses that exceed recommended maximum dose

Beta-adrenergic blockers
These agents inhibit chronotropic, inotropic, and vasodilatory responses to beta-adrenergic stimulation.

Propranolol (Inderal, Betachron E-R)

DOC to counter peripheral action of thyroid hormone; blocks beta-adrenergic receptors; prevents conversion of T4 to T3.

Dosing

Adult

60-80 mg PO q4h
0.5-1 mg IV
Plasma level of 50 ng/mL
required for adequate effect

Pediatric

Not established

Interactions

Coadministration with aluminum salts, barbiturates, NSAIDs, penicillins, calcium salts, cholestyramine, and rifampin may decrease
propranolol effects; calcium channel blockers, cimetidine, loop diuretics, and MAOIs may increase toxicity of propranolol; toxicity of
hydralazine, haloperidol, benzodiazepines, and phenothiazines may increase with propranolol

Contraindications

Documented hypersensitivity; uncompensated congestive heart failure; bradycardia, cardiogenic shock; A-V conduction abnormalities

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Beta-adrenergic blockade may decrease signs of acute hypoglycemia and hyperthyroidism; abrupt withdrawal may exacerbate
symptoms of hyperthyroidism, including thyroid storm; withdraw drug slowly and monitor closely

10 of 15 05.09.2009 00:02
Thyroid, Thyrotoxic Storm Following Thyroidectomy: [Print] - eMedici... http://emedicine.medscape.com/article/850924-print

Esmolol (Brevibloc)

Ultra–short-acting agent that selectively blocks beta1-receptors with little or no effect on beta2-receptor types. Particularly useful in
patients with elevated arterial pressure, especially if surgery is planned. Shown to reduce episodes of chest pain and clinical cardiac
events compared with placebo. Used successfully in thyrotoxicosis and thyroid storm. Can be discontinued abruptly if necessary.
Useful in patients at risk for experiencing complications from beta-blockade; particularly those with reactive airway disease,
mild-moderate LV dysfunction, and/or peripheral vascular disease. Short half-life of 8 min allows for titration to desired effect and quick
discontinuation if needed.

Dosing

Adult

500 mcg/kg IV followed by 50-200 mcg/kg minimum maintenance

Pediatric

Not established

Interactions

Aluminum salts, barbiturates, NSAIDs, penicillins, calcium salts, cholestyramine, and rifampin may decrease bioavailability and plasma
levels of esmolol, possibly resulting in decreased pharmacologic effect; cardiotoxicity of esmolol may increase when administered
concurrently with sparfloxacin, astemizole, calcium channel blockers, quinidine, flecainide, and contraceptives; toxicity of esmolol
increases when administered concurrently with digoxin, flecainide, acetaminophen, clonidine, epinephrine, nifedipine, prazosin,
haloperidol, phenothiazines, and catecholamine-depleting agents

Contraindications

Documented hypersensitivity; uncompensated congestive heart failure; bradycardia; cardiogenic shock; and A-V conduction
abnormalities

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Beta-adrenergic blockers may mask signs and symptoms of acute hypoglycemia and clinical signs of hyperthyroidism; symptoms of
hyperthyroidism, including thyroid storm, may worsen when medication is abruptly withdrawn; withdraw drug slowly and monitor patient
closely

Antihypertensive agents
These agents reduce blood pressure.

Guanethidine (Ismelin)

For use in patients with congestive cardiac failure, bronchospasm, or history of asthma.

Dosing

Adult

1-2 mg/kg/d PO

Pediatric

Not established

Interactions

Tricyclic antidepressants, methylphenidate, thioxanthenes, phenothiazines, sympathomimetics, anorexiants, and haloperidol may
reduce effects of guanethidine; minoxidil, epinephrine, and norepinephrine may increase the toxicity of guanethidine

Contraindications

Documented hypersensitivity; cardiovascular collapse; shock

11 of 15 05.09.2009 00:02
Thyroid, Thyrotoxic Storm Following Thyroidectomy: [Print] - eMedici... http://emedicine.medscape.com/article/850924-print

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in congestive heart failure, asthma, peptic ulcer disease, and regional vascular disease

Reserpine

For use in patients with congestive cardiac failure, bronchospasm, or history of asthma; successful treatment has been documented in
cases of thyroid storm resistant to large doses of propranolol.

Dosing

Adult

2.5-5 mg IM q4-6h

Pediatric

Not established

Interactions

Concurrent use of tricyclic antidepressants may decrease antihypertensive effects of reserpine; cardiac arrhythmias may develop when
either digitalis or quinidine are concurrently administered with reserpine

Contraindications

Documented hypersensitivity; cardiovascular collapse; shock

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in patients diagnosed with renal impairment and peptic ulcer disease

Follow-up

Further Inpatient Care

Combined use of propylthiouracil, iodine, and dexamethasone has an effect within 24-48 hours, and the serum levels of T3 and
T4 return to normal. Clinical signs of decreasing pulse, normal temperature, and improved mental status mark effective
management. Complete recovery takes 10-12 days. Dexamethasone can be tapered thereafter.

The three modalities of definitive management are radioiodine, antithyroid drugs, and surgery.

Prior to radioiodine therapy or surgery, a patient should be made euthyroid with antithyroid drugs and propranolol. Antithyroid
drugs are administered for 12-24 months, during which, a remission may occur. Antithyroid drugs are continued until a normal
metabolic state is reached. If in remission, the patient should be closely monitored for 6 months, as relapse is more common
during this period after discontinuation of therapy. Iodine is progressively withdrawn. Serially monitor patients until the thyroid
gland is sufficiently depleted of its hormone to allow radioiodine therapy. Delaying radioiodine ablation for several months may
be necessary because of the large doses of iodine used in management of thyroid storm. Some surgeons may reintroduce
iodine for 10 days prior to surgery if subtotal thyroidectomy is planned. Follow patients for up to 5 years.

Criteria established by Burch and Wartofsky help in early recognition of impending storm. In thyroid storm, management as
described improves the chance of survival.2

Deterrence/Prevention

Identification of precipitating factors


Surgery and anesthesia induction, labor, thioamide withdrawal, and use of radioiodine are known precipitants of thyroid
storm. However, these precipitants may not be discovered frequently.

12 of 15 05.09.2009 00:02
Thyroid, Thyrotoxic Storm Following Thyroidectomy: [Print] - eMedici... http://emedicine.medscape.com/article/850924-print

Precipitating factors are not found in all patients, but a meticulous search improves chances for a successful outcome.
Chest radiographs and blood, urine, and sputum cultures may be needed to identify intercurrent illness (eg, infection).
Judicious use of empiric antibiotics is needed if no obvious source is found.

Prevention of recurrence
Prevention of a recurrent crisis should be the main objective until completion of definitive therapy.
Vigilant monitoring of signs and symptoms of hyperthyroidism during preoperative or pre-anesthetic evaluation is
paramount.
Consider precipitating factors when deciding on treatment modalities.
Adequate control of the thyrotoxic state prior to initiation of definitive therapy is important. Carry out procedures only after
the patient is euthyroid.

Patient Education
For excellent patient education resources, visit eMedicine's Endocrine System Center. Also, see eMedicine's patient education articles
Thyroid Problems and Thyroid Storm.

Multimedia

Media file 1: Pathophysiologic mechanisms of Graves disease relating thyroid-stimulating immunoglobulins to


hyperthyroidism and ophthalmopathy. T4 is levothyroxine. T3 is triiodothyronine.

13 of 15 05.09.2009 00:02
Thyroid, Thyrotoxic Storm Following Thyroidectomy: [Print] - eMedici... http://emedicine.medscape.com/article/850924-print

References

1. Lahey FH. Apathetic thyroidism. Ann Surg. 1931;93:1026-30.

2. Burch HB, Wartofsky L. Life-threatening thyrotoxicosis. Thyroid storm. Endocrinol Metab Clin North
Am. Jun 1993;22(2):263-77. [Medline].

3. Martin D. Disseminated intravascular coagulation precipitated by thyroid storm. South Med J. Feb 2009;102(2):193-5. [Medline].

4. Brooks MH, Waldstein SS, Bronsky D, Sterling K. Serum triiodothyronine concentration in thyroid storm. J Clin Endocrinol
Metab. Feb 1975;40(2):339-41. [Medline].

5. Ecker JL, Musci TJ. Treatment of thyroid disease in pregnancy. Obstet Gynecol Clin North
Am. Sep 1997;24(3):575-89. [Medline].

6. Gavin LA. Thyroid crises. Med Clin North Am. Jan 1991;75(1):179-93. [Medline].

7. Ingbar SH. Management of emergencies. IX. Thyrotoxic storm. N Engl J Med. Jun 2 1966;274(22):1252-4. [Medline].

8. Mackin JF, Canary JJ, Pittman CS. Thyroid storm and its management. N Engl J Med. Dec 26 1974;291(26):1396-8. [Medline].

9. Mazzaferri EL, Skillman TG. Thyroid storm. A review of 22 episodes with special emphasis on the use of guanethidine. Arch
Intern Med. Dec 1969;124(6):684-90. [Medline].

10. Migneco A, Ojetti V, Testa A. Management of thyrotoxic crisis. Eur Rev Med Pharmacol
Sci. Jan-Feb 2005;9(1):69-74. [Medline].

11. Milham S Jr. Scalp defects in infants of mothers treated for hyperthyroidism with methimazole or carbimazole during
pregnancy. Teratology. Oct 1985;32(2):321. [Medline].

12. Nakamura S, Nishmyama T, Hanaoka K. [Perioperative thyroid storm in a patient with undiscovered
hyperthyroidism]. Masui. Apr 2005;54(4):418-9. [Medline].

13. Prihoda JS, Davis LE. Metabolic emergencies in obstetrics. Obstet Gynecol Clin North Am. Jun 1991;18(2):301-18. [Medline].

14. Rosenberg IN. Thyroid storm. N Engl J Med. Nov 5 1970;283(19):1052-3. [Medline].

15. Scholz GH, Hagemann E, Arkenau C, Engelmann L, Lamesch P, Schreiter D. Is there a place for thyroidectomy in older patients
with thyrotoxic storm and cardiorespiratory failure?. Thyroid. Oct 2003;13(10):933-40. [Medline].

16. Tietgens ST, Leinung MC. Thyroid storm. Med Clin North Am. Jan 1995;79(1):169-84. [Medline].

17. Tintillani JE, Kelen GD, Stapazynski JS. Emergency Medicine A Comprehensive Study Guide. 5th ed. McGraw-
Hill;1999:1343-1345.

18. Utiger RD. The thyroid physiology; hyperthyroidism, hypothyroidism, and the painful thyroid. In: Endocrinology and
Metabolism. 2nd ed. New York, NY: McGraw-Hill;1987:438.

19. Wing DA, Millar LK, Koonings PP, et al. A comparison of propylthiouracil versus methimazole in the treatment of
hyperthyroidism in pregnancy. Am J Obstet Gynecol. Jan 1994;170(1 Pt 1):90-5. [Medline].

Keywords
thyrotoxic storm, thyroid storm, thyrotoxic crisis, thyroidectomy, thyroid disease, extreme hyperthyroid state, toxic goiter surgery,
thyrotoxicosis, Graves disease, toxic goiter

Contributor Information and Disclosures

Author

Nafisa K Kuwajerwala, MD, Staff Surgeon, Breast Oncology, William Beaumont Hospital
Nafisa K Kuwajerwala, MD is a member of the following medical societies: American College of Surgeons
Disclosure: Nothing to disclose.

Coauthor(s)

Gunateet Goswami, MD, Consulting Staff, Internal Medicine Associates, Mount Clemens, Michigan; Consulting Staff, Department of

14 of 15 05.09.2009 00:02
Thyroid, Thyrotoxic Storm Following Thyroidectomy: [Print] - eMedici... http://emedicine.medscape.com/article/850924-print

Cardiology, Henry Ford Hospital


Gunateet Goswami, MD is a member of the following medical societies: American Medical Association, American Society of
Echocardiography, and Michigan State Medical Society
Disclosure: Nothing to disclose.

Thabet Abbarah, MD, FACS, Consulting Staff, Department of Otolaryngology, North Oakland Medical Centers
Thabet Abbarah, MD, FACS is a member of the following medical societies: American College of Surgeons
Disclosure: Nothing to disclose.

Venkata Subramanian Kanthimathinathan, MD, Staff Physician, Department of General Surgery, Loma Linda University Medical
Center
Disclosure: Nothing to disclose.

Pankaj Chaturvedi, MBBS, MS, Associate Professor, Head and Neck Surgery, Department of Surgical Oncology, Tata Memorial
Hospital, India
Pankaj Chaturvedi, MBBS, MS is a member of the following medical societies: American Association for the Advancement of Science
and Association of Surgeons of India
Disclosure: Nothing to disclose.

Medical Editor

Mimi S Kokoska, MD, Associate Professor, Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for
Medical Sciences; Chief, Department of Otolaryngology-Head and Neck Surgery, Central Arkansas Veterans Healthcare System
Mimi S Kokoska, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery,
American Academy of Otolaryngology-Head and Neck Surgery, American College of Physician Executives, American College of
Surgeons, American Head and Neck Society, and Arkansas Medical Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine


Disclosure: eMedicine Salary Employment

Managing Editor

Dean Toriumi, MD, Department of Otolaryngology, Associate Professor, University of Illinois Medical Center
Disclosure: Nothing to disclose.

CME Editor

Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director,
Treasure Coast Sleep Disorders
Christopher L Slack, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and
Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of
Medicine
Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive
Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Head and Neck Society
Disclosure: Covidien Corp Consulting fee Consulting; US Tobacco Corporation unstricted gift unknown; Axis Three
Corporation Ownership interest Consulting; Omni Biosciences Ownership interest Consulting; Sentegra Ownership interest Board
membership; Syndicom Ownership interest Consulting; Oxlo Consulting; Medvoy Ownership interest Management position

Further Reading
© 1994-2009 by Medscape.
All Rights Reserved
(http://www.medscape.com/public/copyright)

15 of 15 05.09.2009 00:02

Das könnte Ihnen auch gefallen