What Causes This Disease And How Frequent Is It
Graves disease occurs in approximately 1:5,000 children. There is no seasonal variation. The peak age of Graves disease is in adolescence it is more common in females . Other causes make up less than 10% of cases of thyrotoxicosis in children. Hyperfunctioning adenomas or toxic multinodular goiter occur at any age , with an equal sex ratio. The incidence of thyroid storm is unknown, but it appears to be a rare complication of thyroxicosis in children.
Graves disease is an autoimmune disorder. It is not infectious or transmissible. As described above, an acute infection may precipitate thyroid storm in a patient with thyrotoxicosis.
Genetics: Graves disease is an autoimmune disorder characterized by a genetic predisposition with an environmental trigger. Graves disease is associated with certain HLA haplotypes which appear to be linked with changes in immune function. Some hyperfunctioning adenomas and toxic multinodular goiters have been shown to be the result of activating mutations in the TSH receptor these may be inherited in an autosomal dominant fashion. There is no described genetic predisposition to thyroid storm.
Are There Any Risks To Hyperthyroidism Treatments
With most treatments, there are also risks of side effects. Its important to talk to your healthcare provider and weigh all of the pros and cons before deciding on a treatment plan. Some of these risks include:
After treatment, you will most probably need to take replacement thyroid hormone for the rest of your life. This is because some of these treatments especially surgery reduce your thyroid hormone levels to very low levels or eliminate this hormone by removing your thyroid. Youll need to re-introduce the thyroid hormones back into your system by taking regular medication.
Diagnosis Of Thyroid Storm
The diagnosis of thyroid storm is highly based on clinical assessment. It may also be more difficult to diagnose compared to other conditions due to its multisystem involvement. When thyroid storm is suspected, early treatment is necessary to reduce mortality and other serious complications.
- Physical assessment and medical history taking these two processes are important in the diagnosis of thyroid storm. The basic parameters such as the vital signs and the presence of signs and symptoms will be evaluated and reviewed by the physician.
- Laboratory tests blood tests including the measurement of thyroid stimulating hormone will be taken. It may be expected to get a normal to below normal TSH level in people with thyroid storm. The levels of T3 and T4 will also be measured and will be expected to be higher than normal.
- Differential diagnosis an approach to diagnose thyroid storm is to rule out other possible medical conditions. The following are associated conditions with similar clinical manifestations to thyroid storm:
- Sympathomimetic toxicity
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Thyroid Storm Nclex Review Care Plans
Nursing Study Guide on Thyroid Storm
Thyroid storm is a life-threatening medical emergency associated with exacerbated clinical manifestations of thyrotoxicosis. Thyroid storm is also called other names such as hyperthyroid crisis, thyroid crisis, and thyrotoxic crisis.
It is a rare condition that has become even less common due to improved treatments for hyperthyroidism. Thyroid storm may be difficult to diagnose due to its multi-system involvement.
Everything You Need To Know About Thyroid Storm
Thyroid Storm or thyrotoxic crisis is a life-threatening situation which happens due to absence or poor treatment of hyperthyroidism. Although its a rare condition, it is highly critical and severe in nature. It can lead to rapid irregularities in heart rate, fever, nausea, heart failure and even death if not treated properly in time.
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Causes And Risk Factors
The primary risk factor for thyroid storm is having untreated Graves’ disease and/or hyperthyroidism.
Even when the Graves’ disease is identified and being treated, there are a number of other factors that raise your risk of thyroid storm:
- Infection, specifically lung infections, throat infections, or pneumonia
- Blood sugar changes, including diabetic ketoacidosis and insulin-induced hypoglycemia
- Recent surgery on your thyroid gland or trauma to your thyroid
- Abrupt withdrawal of your antithyroid medications
- Radioactive iodine treatment of your thyroid
- Excessive palpation of your thyroid gland
- Exposure to a large quantity of iodine
- Severe emotional stress
Complications of thyroid storm include stroke and heart attack, which can lead to death.
Can I Get Hypothyroidism From My Hyperthyroidism Treatment
You can get hypothyroidism from hyperthyroidism treatments. This is sometimes the goal of a healthcare provider. In hypothyroidism, the amount of thyroid hormone needs to be boosted. This can be done with medications that you regularly take. Adding hormones to your body is more manageable than trying to get your body to decrease the amount of thyroid hormone it creates.
Can hyperthyroidism cause female infertility?
One of the symptoms of hyperthyroidism in women can be irregular menstrual cycles . The imbalance of thyroid hormone can impact all parts of your body. Some women actually start reaching out to their healthcare provider because of issues becoming pregnant and then learn about a thyroid condition.
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Spotlight On Aging: Hyperthyroidism In Older People
Hyperthyroidism affects about the same percentage of older people as younger peopleabout 1%. However, hyperthyroidism is often more serious among older people because they tend to have other disorders as well.
Hyperthyroidism in older people often results from Graves disease. Almost as often, hyperthyroidism is caused by the gradual growth of many small lumps in the thyroid gland .
Some drugs can cause hyperthyroidism as well. The most common is amiodarone, a drug used to treat heart disease but which may stimulate or damage the thyroid gland.
Hyperthyroidism can cause many vague symptoms that can be attributed to other conditions. Typically, symptoms are different in older and younger people.
Among older people, the most common symptoms are weight loss and fatigue. The heart rate may or may not be increased, and the eyes usually do not bulge. Older people are also more likely to have abnormal heart rhythms , other heart problems , and constipation.
Occasionally, older people sweat profusely, become nervous and anxious, and have hand tremors and frequent bowel movements or diarrhea.
What Complications Of Hyperthyroidism Can Affect My Body
Hyperthyroidism can impact many parts of your body. Different systems, ranging from your vascular system to your skeletal system can all be affected if you have an overactive thyroid.
When you have hyperthyroidism, it may feel like your heart is beating very quickly. This rapid heartbeat is a symptom of the condition thats caused by your fast metabolism. The body is running faster than normal when you have hyperthyroidism, making you feel like your heart is racing. Having an irregular heartbeat can increase your risk of different medical conditions, including stroke.
The bones are the support structure for your body. When you have unchecked high levels of thyroid hormones, your bones can actually become brittle. This can lead to a condition called osteoporosis.
Eyes and Skin
Hyperthyroidism can be caused by a medical condition called Graves disease. This disease can affect both your eyes and skin. It can cause you to have several eye problems, including:
- Bulging eyes.
- Double vision and light sensitivity.
- Redness and swelling of the eyes.
Graves disease can also cause your skin to become red and swollen. This is particularly noticeable on the feet and shins.
Another complication of hyperthyroidism is something called a thyroid storm . This is a sudden and dramatic increase in your symptoms. When this happens, your heart may beat even faster than normal and you may develop a fever. A thyroid storm is an emergency situation.
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Recommendations Based On The Japanese Experience
For the first time, the proposed guidelines by this Japanese research team are based on solid evidence and were endorsed by professional organizations including the American Thyroid Association , Dr. Akamizu says. Some of the changes in treatment are at odds with the ATA guidelines, but the mainstays of managementsuch as needing a team of doctors to handle the crisisare the same.1-3
The key points that Dr. Akamizu says those with hyperthyroidism need to know about thyroid storm, based on the changes to care that are presented in the review paper,1 and from his years of clinical experience are as follows:.
o body temperature of 100 degrees or more
o rapid heart rate
o blood pressure over 130
o unusual or unexplained changes in consciousness, diarrhea, vomiting, jaundice.
While some of these conditions are more likely to point to other health concerns, if you experience some of these all at once, it is crucial to get medical help or advice.
Adverse Side Effects From Antithyroid Drugs
Since 2010, the US Food and Drug Administration has added a boxed warning to the prescribing information of PTU to include information about reports of severe liver injury and acute liver failure, some of which have been fatal, in adult and pediatric patients using this medication. The US Food and Drug Administration recommends that PTU be reserved for patients who cannot tolerate methimazole. PTU is preferred only in the case of pregnant women during the first trimester as methimazole use during this period had been associated with teratogenicity. Nevertheless, methimazole is suggested for use during the second and third trimesters of pregnancy.
Treatment aim 3: inhibition of hormone release
Lugol solution, potassium iodide, or ipodate can be given to stop thyroid hormone release. Thionamide therapy must be instituted first, and these drugs only given at least 1âh later. Iodine therapy blocks the release of prestored hormone and decreases iodide transport and oxidation in follicular cells. Lugol solution can be given three to four times to a total of 30â40 drops/day. Initial treatment may start with 8â10 drops. Lugol solution provides 8âmg iodide/drop.
Treatment aim 4: preventing peripheral conversion of thyroxine to triiodothyronine
Treatment aim 5: Î²-adrenergic receptor blockade
Treatment aim 6: identifying precipitating factors
Consequent management and definitive therapy
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Pharmacological Management Of Thyroid Storm
- Antithyroid medications :
- Tapazole Methimazole: has fewer side effects than PTUnot for first trimester of pregnancy
- PTU Propylthiouracil: can be used during 1st trimesterwatch for liver failure
Side Effects with these medications: Agranulocytosis and thrombocytopenia and watch for toxicity which will present as signs and symptoms of HYPOTHYROIDISM: slow heart rate, intolerance to cold, drowsy
- Iodide solution
- Lugols solution: Side effects: taste changes metal taste in mouth
2. Decrease fever:
Tylenol NO Salicylates or cooling blankets
3. Decrease effects of thyroid hormones on the body by blocking peripheral conversion of T3 and T4:
- Beta Blockers: Inderal
4. Prevent further secretion and conversion of thyroid hormones by suppressing immune system with:
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Initial Actions And Primary Survey
Thyroid storm is exceedingly uncommon in the ED but it should be considered in any patient presenting with a hypermetabolic state, and especially those with a history of thyroid disease. Determining where the symptoms of subacute or chronic thyrotoxicosis end and thyroid storm begins is difficult. The focus of the primary survey and the subsequent detailed history and physical examination is to identify those patients at risk for thyroid storm.
Prior to entering the room, review the vital signs. Fever and tachycardia are common findings in thyroid storm. Tachypnea may be seen, particularly in the setting of complicating heart failure. Hypertension and a widened pulse pressure may also be present. The patient may also be agitated and/or anxious.
Airway: The airway is typically not compromised by thyroid storm. However, these patients are often critically ill and the complications or inciting etiology of the patients thyroid storm may require active airway intervention.
Breathing: Tachypnea may occur for numerous reasons: increased basal metabolic rate underlying heart failure as a complication of long standing thyrotoxicosis or other diseases that precipitated thyroid storm .
While performing a primary survey, as with any seriously ill patient, the following should be obtained:
- Reliable vascular access, cardiac, SpO2, and BP monitoring. Supplemental oxygen if needed.
- Bedside pointof-care glucose.
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Case Reports/ Case Studies
1. Intraoperative Thyroid Storm: A Case Report
Case report of an 18 year old female who was 1 year post diagnosis of Graves Disease and was underwent elective thyroidectomy surgery. 30 minutes into the surgery the patients heart rate and temperature started to rise. Treatment was performed to combat the thyroid crisis and the surgery to remove her thyroid was completed.
2.Thyroid Storm Precipitated by Duodenal Ulcer Perforation
Thyroid storm triggered by a gastrointestinal perforation in a 55 year old Japanese man. Admitted to the hospital for leg edema and acute severe abdominal pain. On arrival he presented with tachycardia with a goiter, altered consciousness, atrial fibrillation, and swelling of the abdomen.
3. Thyroid Storm during induction of anesthesia Case report of a 50 year old woman who experienced a thyroid storm during anesthesia induction for a humeral fracture repair. Patient presented with no history of hyperthyroidism nor abnormal signs preoperatively. However, reported weight loss, intermittent palpitations, and hand tremors for the past year.
Increases In Free Thyroid Hormone
Individuals with thyroid storm tend to have increased levels of free thyroid hormone, although total thyroid hormone levels may not be much higher than in uncomplicated hyperthyroidism. The rise in the availability of free thyroid hormone may be the result of manipulating the thyroid gland. In the setting of an individual receiving radioactive iodine therapy, free thyroid hormone levels may acutely increase due to the release of hormone from ablated thyroid tissue.
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Treatment For Thyroid Storm
In the management of thyroid storm, treatment may begin prior to the arrival of test results. This is because of its associated mortality rate and serious complications. The main goals of the treatment for thyroid storm are the following:
- To block the production of thyroid hormones
- To block the sympathetic flow
- To block the conversion of T4 to T3
Several methods are found helpful in the management of thyroid storm:
What Is The Evidence
Burch, HB, Wartofsky, L. Life-threatening thyrotoxicosis. Thyroid storm. Endocrinol Metab Clin North Am. . vol. 22. 1993. pp. 263-277.
Isozaki, O, Satoh, T, Wakino, S. Treatment and management of thyroid storm: analysis of the nationwide surveys: The taskforce committee of the Japan Thyroid Association and Japan Endocrine Society for the establishment of diagnostic criteria and nationwide surveys for thyroid storm. Clin Endocrinol. 2015 Sept 21.
Aslan, IR, Baca, EA, Charlton, W, Rosenthal, SM. Respiratory syncytial virus infection as a precipitant of thyroid storm in a previously undiagnosed case of Graves’ disease in a prepubertal girl. Int J Pediatr Endocrinol. 2011. pp. 138903
Lee, HS, Hwang, JS. Seizure and encephalopathy associated with thyroid storm in children. J Child Neurol. vol. 26. 2011. pp. 526-528.
Cao, LY, Wei, H, Wang, ZL. Neonatal thyroid storm accompanied with severe anemia. J Pediatr Endocrinol Metab. vol. 28. 2015. pp. 773-776.
Mailesi, MN, Greller, HA, McGuigan, MA. Thyroid storm after pediatric levothyroxine ingestion. Pediatrics . vol. 126. 2010. pp. e470-3.
Landgraf, L, Grubina, R, Chinsky, J. Altered mental status in a 16-year-old girl: the calm before the storm. Clin Pediatr. . vol. 47. 2008. pp. 720-724.
Morrison, MP, Schroeder, A. Intraoperative identification and management of thyroid storm in children. Otolaryngol Head Neck Surg. vol. 136. 2007. pp. 132-133.
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If You Are Able To Confirm That The Patient Has Thyroid Storm What Treatment Should Be Initiated
It is important to evaluate patients for a precipitating cause of thyroid storm. If a cause is identified, e.g., an acute infection, an appropriate antibiotic and other supportive treatment should be initiated. Seizures should be treated with an anti-convulsant.
Details of drug treatment:
1. Beta adrenergic antagonists choose one of:
Propranolol 1-2 mg/kg/24 hr by mouth divided every 6 to 8 hrs.
If unable to take by mouth: 0.01-.10 mg/kg IV every 6 to 8 hrs
Atenolol 1-2 mg/kg by mouth once daily this cardioselective beta blocker may be preferred in patients with a history of reactive airway disease
Esmolol loading dose 250-500 mcg/kg IV over 1-3 min, then 50-100 mcg/kg per minute esmolol is a short-acting beta blocker used to achieve rapid control of adrenergic nervous system signs, e.g., tachycardia, with quick titration to clinical response.
2. Anti-thyroid drugs choose one of:
3. Iodine choose one of:
Lugols solution 1 drop by mouth 3 times daily
SSKI 1 drop by mouth daily
Iodine should not be started until an hour after the first dose of PTU or MMI. Iodine can be toxic to esophageal and intestinal mucosa it should be diluted in another liquid. Overdosing of SSKI has been reported to cause hyperkalemia and arrhythmias.
Hydrocortisone 1-2 mg/kg IV every 8 hrs
What Are The Adverse Effects Associated With Each Treatment Option
1. Beta adrenergic antagonists adverse effects include bradycardia, hypotension, and bronchospasm, and, as with most drugs, hypersensitivity reaction.
2. Anti-thyroid drugs adverse effects with PTU and MMI are generally divided into minor and major adverse effects:
Minor side effects include skin rashes , arthralgias, abnormal taste sensation, and transient granulocytopenia .
Major side effects include a lupus-like syndrome with a vasculitis and glomerulonephritis, hepatitis, and agranulocytosis. Development of any of these major side effects necessitates immediate discontinuation of the anti-thyroid drug and precludes any future use.
3. Iodine Either Lugols solution or SSKI may cause esophageal or small intestine mucosal injury and hemorrhage. Overdosage with SSKI may lead to hyperkalemia and arrhythmia.
4. Glucocorticoids High-dose administration of glucocorticoids may cause hyperglycemia, fluid retention with edema and elevated BP, GI ulceration, suppression of immune function leading to impaired wound healing, and Cushings syndrome. As noted above, steroids should be discontinued with resolution of thyroid storm.
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