Normal laboratory value related to thyroid gland:-
- Thyroid - Stimulating Hormone (TSH) :- 0.4 -4.0 microU/ml
- Thyroid- Stimulating Immunoglobulin (TSI):- < 130% of basal activity
- Thyroxine (total T4):- 4.5 - 11.2 micro gram /dl (58-144 nmol/L SI units)
- Thyroxine -Binding Globulin (TBG):- 1.3 - 2.0 mg/dl
- Thyroxine ( Free T4, FT4):- 0.8 - 2.7 NG/dL (10-35 pmol/L SI units)
Causes
- Stroke
- Congestive heart failure
- Pulmonary embolism
- Diabetic ketoacidosis
- Severe emotional stress
- Trauma direct to thyroid gland
- Surgery
- Sepsis
- Anesthesia induction
- Radioactive iodine
- Excessive thyroid hormone ingestion
- Drugs( anticholinergic and adrenergic)
- Vigorous palpation on an enlarged thyroid
- Toxemia of pregnancy and labor
- Molar pregnancy
- Hyper function of thyroid nodules
- Hyper function of multi-nodular goiter
Sign and symptoms
All the symptoms of Hyperthyroidism-- High grade fever (over 39.8 degree Celsius)
- Persistent sweating
- Shaking
- Diarrhea
- Agitations
- Restlessness
- Mental status altered( eg; confusion, Seizers
- ,etc)
- Tachycardia ( exceed heart beat over 140 beats per minutes.)
- Heat intolerance
- Palpitations
- Vomiting
- Hypertension
- Hpotensive ( later)
- Wt. loss
- Shock
- Possibly coma
- High metabolic rate
- Exophthalmus
Investigation
- The Best first step is a determining of TSH level .In this case TSH level mainly low than normal, T4 & T3 level always higher than normal values.
- Severity of hyperthyroidism ,thyrotoxicosis and thyroid storm assessed with Burch -Wartofsky score. This score is obtained from different clinical parameters ( eg; temperature ,severity of agitation ). If this score below 25 excludes thyroid stom, 25-45 suggest risk and above 45 conform thyroid storm.
- Besides these check vitals and clinical evaluations of patient and patient personal history, patient medical history as well as family history that plays great role too.
Treatment thyroid storm
- As it's emergency situation and if there is shock check for ABCs and soon as possible patient should be admitted in ICU .
- Supporting measures like cooling blankets may be used.
- First step is to put patient on IV fluids with dextrose solution, electrolyte replacement and nutritional support .
- The best initial step in management of this patient by IV Propylthiouracil (PTU) .
- PTU orally or via a NG tube in unresponsive patients with loading dose of 600 mg followed by a dose of 200-250 mg every 4 - 6 hrs.
- Carbimazole or Methimazole is administered at a dose of 20 - 30 mg every 4 - 6 hrs.
- symptoms like palpitation, tachycardia, arrhythmia treat with propranolol ( IV 1-3 mg at a rate not exceeding 1 mg/ min. A second dose may be given after 2 min.
- IV dexamethasone (8 mg daily for 3 days) can be used in order to inhibit peripheral conversion of T4 to T3.
- Inorganic iodide (potassium iodide)
- In high grade fever Paracetamol / Acetaminophen 500 mg orally twice or thrice a day can be taken.
- Others symptomatic treatments should be done .
- Treatment of underlying cause.
- Maintain of healthy life style.
- Regular exercise
- Healthy hygienic habits and healthy food diets.
Prognosis
If not treated this case in time fatal in adult ( 90% mortality rate) and similarly outcome in children too although this case is rare in children. Death in this case is mainly of cardiac arrhythmia , congestive heart failure , hyperthermia , multiple organ failure, etc. Just temperature controlled in thyroid storm mortality rate risk is reduced by 20%.
Following factors associated with increase mortality risk in thyroid storm -
- Age 60 yrs over.
- CNS dysfunction at time of admission .
- Lack of beta blocker and anti thyroid drug use.
- Need for mechanical ventilation and plasma exchange along with hemodialysis.
