Thyroid Storm

(Krisis Tiroid)
Dr. dr. Shahrul Rahman, Sp.PD, FINASIM

Departemen Ilmu Penyakit Dalam

Fakultas Kedokteran
Universitas Muhammadiyah Sumatera Utara
 Thyroid Storm

The acute exacerbation of all of the

symptom of thyrotoxicosis.
A life-threatening crisis .
Estimated mortality : 20-30% the result of
thyroid surgery .
Caused more often by antecedent Graves
disease .
 Thyroid Storm

Extreme form of thyrotoxicosis

Uncommon
Usually associated with
preexisting thyrotoxicosis
Graves Disease
Toxic multinodular goiter
Abrupt onset
 Precipitants of Thyroid Storm
Surgery .
Radioiodine therapy .
Parturition
Iodinated contrast dyes .
Thyroid hormone ingestion .
Diabetic Ketoacidosis .
Acute infection, trauma, severe drug reaction,
myocardial infection
Cerebrovascular accident .
Pulmonary embolism and CHF .
 Pathophysiology of Thyroid
Storm
An acute decrease in thyroxine-binding globulin
(TBG) decreased binding to TBG high
levels of free hormone ( T3 & T4 ) .
Thyroid hormone increases the density of beta-
adrenergic receptors & alters responsiveness to
catecholamines at a postreceptor level .
The number of binding sites for cathecolamine
increases increased sensitivity to circulating
cathecolamine
 Diagnosis of Thyroid Storm
Largely a clinical diagnosis .
Clinical manifestation are :
- marked hypermetabolism
- excessive adrenergic response
Clinical manifestation :
- fever 38-41C
- flushing
- sweating
- marked tachycardia ( ventricular tachyarrithmia )
- atrial fibrilation
- high pulse pressure
- may complicated high output CHF
 CNS disturbances occur in 90% of patients :
- marked agitation
- restlessness
- delirium
- coma
Gastrointestinal symptom :
- nausea
- vomiting
- diarrhea
- jaundice
Fatal outcome is associated with :
- heart failure
- shock
- cardiac arrythmia

Many of the stigmata of the hyperthyroid state may be

present .
 Laboratory Diagnosis of
Thyroid Storm

A combination of low TSH and elevated

free T4 makes the diagnosis .
If TSH is lower than normal and free T4 is
normal free T3 testing is recommended .
Measurement of thyroglobulin or thyroid
antibodies No indication .
 Treatment of Thyroid Storm

Block hormone synthesis with either :

a) Propylthiouracil 100-600 mg loading
PO or NG , 200-250 mg q4h for total daily
dose of 1200-1500 mg ; or
b) methimazole 20 mg PO ( 10-40 mg
range ) q 4h .
 Treatment of Thyroid Storm
( continued )

Inhibit hormone release :

Iodides Potassium iodide ( SSKI ) 5 drops PO
Q6-8H , or
Lugols solution 7-8 drops ( 1 mL PO Q6H ) or
Ipodate 1-3 g daily ( as 1 g Q8H for 24 hours ,
then 500 mg Q12H ) .
If severe iodide allergy , lithium carbonate 300
mg Q6H .
 Treatment of Thyroid Storm
( continued )
Glucocorticoids : Hydrocortisone ( 300 mg IV ,
then 100 mg IV q8h ) ; dexamethasone ( 2 mg
Q6H ) .
Adrenergic blockade : Propranolol ( 1-2 mg IV
over 15 minutes slow IV every 3 hours or 40-80
mg po every 6 hours ) ; Esmolol ( 0.25-0.5
mcg/kg loading , infusion of 0.05-0.1
mcg/kg/min ) controlling arrythmia
Arrythmia + severe heart failure or asthma
Verapamil 5-10 mg iv
 Treatment of Thyroid Storm
( continued )

Dexamethasone [generic] :
Inhibits further hormone release from gland
Inhibits peripheral synthesis of T3 from T4
Synergistic effect with PTU and iodine
Brings serum T3 concentration to normal
limits within 24-48 hours
Adjunctive Therapy for Thyroid
Storm

Treat fever aggressively with acetaminophen .

IV fluid containing 10% dextrose are
recommended .
Administer vitamin supplements , including
thiamine .
Treat CHF with conventional methods .
Adjunctive Therapy for Thyroid
Storm ( continued )

Identify the precipitating event , including

infection .
Consider plasmapheresis , hemodialysis
or peritoneal dialysis for removal of
metabolically active hormone .