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Medical and endocrine disease · Core07 / 30
Thyroid storm after urgent trauma surgery in unrecognised hyperthyroidism24-year-old man, 64 kg, injured in a road crash 3 hours ago
Thyroid storm: recognition after surgery and the ordered drug treatment
From memory: the diagnosis and the notes are hidden. Answer each question aloud, then press Show.
Know this first
Surgery or trauma in unrecognised thyrotoxicosis can precipitate thyroid storm.
Burch–Wartofsky score of 45 or more is consistent with storm; 25–44 is impending storm.
Block synthesis with a thionamide first; iodide no sooner than 1 hour later.
Storm drugs: PTU 500–1000 mg as a loading dose, 250 mg 4-hourly after; hydrocortisone 300 mg, 100 mg 8-hourly after.
The patient
24-year-old man, 64 kg, injured in a road crash 3 hours ago, for urgent washout and fixation of an open tibial fracture.
Primary survey otherwise clear. This year he has lost weight, has a fine tremor, hates the heat and has a smooth goitre; never investigated.
No regular drugs.
Vitals: BP 148/62, HR 124 regular, SpO2 98% on air, RR 18, temp 37.6 °C.
The examiner asks
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Consider
What are your concerns?
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A 24-year-old trauma patient for urgent open tibial fixation, with signs of untreated hyperthyroidism. Patient
As a trauma patient, I first exclude bleeding, pain or a missed injury as the cause of his rate.
Weight loss, tremor, heat intolerance and a goitre point to thyrotoxicosis. Disease
Untreated, the trauma and the operation can tip him into thyroid storm. Stem trigger
Making him euthyroid takes 6–8 weeks; an open fracture can't wait, so this is an emergency-only case. Surgery
Prepare
What can you do to prepare him before theatre?
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TSH, free T4 and free T3 sent, but I don't wait for them. Disease
Beta-blockade before theatre: esmolol by pump at 50–100 mcg/kg/min, titrated to his rate.
With endocrinology: PTU by mouth or tube, plus dexamethasone 2 mg IV every 6 hours.
A deep enough anaesthetic, and no ketamine, ephedrine or atropine to drive his sympathetic tone.
Warned and ready for storm after surgery, which is when it usually appears. After surgery
Crisis
That night on the ward he is 40.2 °C, agitated and confused, in AF at 160 with crackles at both bases. BP 104/58, SpO2 91%. What do you do?
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Thyroid storm until proven otherwise: fever, delirium, fast AF and failure after surgery while untreated. (Crisis)
His Burch–Wartofsky score is far over 45: temperature, delirium, rate, AF, failure and a precipitant.
I keep sepsis from the open wound, MH and NMS in mind; MH usually brings rigidity and a high CK.
Call for help, oxygen, and move him to ICU with endocrinology involved now.
Active cooling with blankets and ice packs, plus paracetamol 1 g IV.
The precipitant is treated too: his wound reviewed and cultures sent.
Crisis
He's in ICU, still in AF at 160 with crackles, BP 100/60. Talk me through his drug treatment.
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Beta-blockade first, carefully given his failure: esmolol 0.1–0.2 mg/kg, infusion only if tolerated. Crisis
Then PTU, 500–1000 mg by tube, then 250 mg 4-hourly, to stop new hormone.
Iodide only an hour after the PTU: SSKI 5 drops 6-hourly; iodide alone would worsen him.
Hydrocortisone 300 mg IV, then 100 mg 8-hourly.
If he becomes shocked, I use phenylephrine, a direct-acting pressor.
His AF may need anticoagulation, timed against his fracture bleeding. After surgery
Storm mortality is around 20%, so he stays in ICU until stable.
Fatal mistakes
Giving iodide before the thionamide.
Labelling the storm as sepsis alone and treating only infection.
A large beta-blocker bolus into thyrotoxic heart failure.
Checked against: Stoelting 8e · Miller 10e · American Thyroid Association guidelines for hyperthyroidism and other causes of thyrotoxicosis (2016)
Mark Got it only if you said every point. Again brings the case back tomorrow; Got it brings it back in 3, then 7, 14 and 30 days.
Same topic, another patient
Run these after the main case when you have time. Same skills, a different patient or setting.
Another patient · Intra-operative crises. Thyroid storm during emergency ankle fixation. Same storm starting intraoperatively: AF, shock, telling it from MH
Know this first
Storm is a clinical diagnosis; thyroid tests don't separate it from simple thyrotoxicosis.
Sequence: beta-blocker, then PTU, then steroid and cooling; iodine waits an hour after the PTU.
Shock in storm: direct vasopressor such as phenylephrine; avoid amiodarone for AF.
Storm and MH look alike; rigidity and a steep CO2 rise point to MH.
The patient
28-year-old woman, 52 kg, for emergency washout and fixation of an open ankle fracture after a motorbike fall.
Six months of weight loss, palpitations and heat intolerance; fine tremor and a smooth goitre; never investigated.
Drugs: none.
Vitals: BP 148/62, HR 124 sinus, SpO2 98% on air, temperature 37.6 °C.
The examiner asks
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Consider
What concerns you about her?
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A 28-year-old with probable untreated hyperthyroidism, for an open ankle fracture that can't wait. Patient
After a motorbike crash she needs a full primary survey, and I treat her stomach as full.
Weight loss, tremor, goitre and HR 124 say thyrotoxicosis that has never been treated. Disease
Untreated thyrotoxicosis plus emergency surgery is the classic set-up for thyroid storm. Stem trigger
I send thyroid tests, but no result diagnoses storm; I'll treat her on clinical signs. Disease
An open fracture can't wait for her to become euthyroid, so storm drugs come to theatre with us. Surgery
Before induction, esmolol titrated to a heart rate under 90. Disease
Crisis
An hour in, her temperature is 39.4 °C and she is in atrial fibrillation at 160. BP 102/50, ETCO2 48 mmHg. What do you do?
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Fever and fast AF under anaesthesia: in her, thyroid storm leads, but MH must be excluded. (Crisis)
I feel for rigidity and watch the CO2 trend; rigidity or a steep CO2 climb means MH.
If MH can't be excluded, volatile off and dantrolene 2.5 mg/kg, while I still treat her thyroid.
Storm, step one: esmolol infusion 50–100 mcg/kg/min to slow her rate and blunt adrenergic drive.
Step two: propylthiouracil 500–1000 mg down the gastric tube, to stop new hormone synthesis.
Step three: hydrocortisone 300 mg IV, which blocks T4-to-T3 conversion and covers her adrenals.
Cooling blankets, ice packs and paracetamol 1 g IV for her fever.
Crisis
Twenty minutes later BP is 74/40, HR 150 in AF, and her lungs are wet. What now?
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Adult tachycardia algorithm: AF at 150, BP 74/40 and wet lungs, so she is unstable. (Crisis)
Synchronised shock at 200 J or more now.
Esmolol paused while she's hypotensive; digoxin 0.25 mg IV for rate; phenylephrine 50–100 mcg boluses.
A direct vasopressor is the advised choice for shock in storm; her fast AF cuts filling.
No amiodarone for her AF: it can worsen thyroid function.
Arterial line and echo to guide fluid, because her failing heart is now wet.
Plan
Surgery is finished. What is your plan now?
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She goes to ICU, still ventilated, for monitoring of her storm. (After surgery)
Potassium iodide 5 drops every 6 hours, started only 1 hour after the first PTU dose.
Propylthiouracil 250 mg every 4 hours and hydrocortisone 100 mg every 8 hours continue.
Cholestyramine 4 g by mouth every 6 hours is an added option to lower her hormone.
Storm still kills about 1 in 10 despite full treatment, so endocrinology takes over today.
Any future thyroid surgery waits until she is controlled on antithyroid drugs.
Fatal mistakes
Giving iodine before propylthiouracil.
Dantrolene with no beta-blocker, PTU or steroid.
Amiodarone for her atrial fibrillation.
Checked against: American Thyroid Association guidelines for hyperthyroidism and other causes of thyrotoxicosis (2016) · Miller 10e · Stoelting 8e · Barash 9e