P031: HOW TO PREPARE FOR A "STORM" –REVIEW OF THE MANAGEMENT OF THYROID STORM IN RELATION TO A CASE WITH THYROID DISEASE
A Valerio, MD1; T Chonis, MD2; I Pop, BS3; L I Rodriguez, MD1; 1University of Miami. Jackson Memorial Hospital; 2Jackson Memorial Hospital; 3University of Miami
Thyrotoxicosis describes disorders of excess thyroid hormone with or without the increased synthesis of thyroid hormone (hyperthyroidism). Thyroid storm is an extreme manifestation of thyrotoxicosis, usually precipitated by some event or underlying condition. In the spectrum of endocrine emergencies, thyroid storm ranks as one of the most critical illnesses. Incidence in general population was reported as 0.57-0.76 per lac per year in USA. Hospital data suggest that it occurs in 1–2% of patients admitted for thyrotoxicosis. It occurs more commonly in women, with a ratio F:M = 3:1. Superimposed precipitating factors cause thyroid storm in patients with diagnosed or undiagnosed hyperthyroidism. It is more common with Graves’ disease but can occur with other etiologies of hyperthyroidism, for example, toxic multinodular goiter and toxic adenoma of the thyroid. The precipitating factors are: Abrupt discontinuation of antithyroid medicine, thyroid surgery, non-thyroid surgery, trauma, acute illness like infections, diabetic ketoacidosis, acute myocardial infarction, cardiovascular accident, cardiac failure, drug reaction, parturition, recent use of Iodinated contrast medium, radioiodine therapy.
We present a case of a 73 yo female with h/o symptomatic thyroid multinodular goiter, HTN, preDM, and thrombocytopenia. Patient reported dysphagia, voice changes and positional shortness of breath. The patient was scheduled for Total Thyroidectomy. On preoperative evaluation, she was found to be clinically euthyroid. General anesthesia induced, and a neural integrity monitor (NIM) ETT placed under videolaryngoscopy guidance. Arterial and peripheral lines obtained. Surgery course was un-eventful and patient was successfully extubated at the end of the case.
The classical features of TS such as abdominal pain, diarrhea, nervousness and restlessness are masked during general anesthesia and only hyperthermia and cardiovascular effects could be the life-threatening signs. The presentation of TS includes fever, profuse sweating, signs of encephalopathy (anxiety, emotional lability, restlessness, agitation, confusion, delirium, frank psychosis, and coma), various cardiac manifestations (sinus tachycardia, atrial arrhythmias, and congestive heart failure), systolic hypertension, and gastrointestinal symptoms (diffuse abdominal pain with abnormal liver enzymes levels).
Diagnostic tests should be obtained and usually show high FT4/FT3 and low TSH. Other lab abnormalities may include hypercalcemia, hyperglycemia, abnormal LFTs, high or low white blood cell (WBC) count. Burch-Wartofsky Point Scale (BWPS) scoring system for the diagnosis of TS (Temperature, CNS dysfunction, tachycardia, presence of atrial fibrillation, heart failure: GI dysfunction, presence of precipitating factor) and The Japanese Thyroid Association (JTA) (elevated FT3 and/or FT4 is a prerequisite, and it requires various combinations of following symptoms: CNS manifestation, fever, tachycardia, CHF, GI/Hepatic Manifestation) are used as diagnostic guidelines.
Management with rapid lowering of thyroid hormone levels, control of thyroid hormone release, and control of peripheral manifestations of thyroid hormone are needed. This include: beta-adrenergic blockade, thionamide, oral cholecystographic agent, corticosteroid and supportive hydration and cooling.