Thyroid storm ED treatment

Question 1

Treatment aims in Thyroid Storm (8)

Answer 1

1. Supportive Care
2. Inhibition of PERIPHERAL Adrenergic effects
3. Inhibition of NEW hormone synthesis
4. Inhibition of Thyroid hormone RELEASE
5. Preventing PERIPHERAL CONVERSION of T4 to T3
6. Preventing Free Thyroid Hormone REABSORPTION
7. Treating Precipitant
8. Definitive Care

Question 2

Supportive Care

How do you manage fever

Answer 2

External cooling: ice packs or cooling blankets
Acetaminophen: 325-600mg PO or PR q4-6

Question 3

Supporitve Care

Why is aspirin contraindicated

Answer 3

May increase free thyroid hormone

Question 4

Supportive Care

Additional Nutrition to Give (4)

Answer 4

1. Glucose
2. Multivitamins
3. Thiamine
4. Folate

Question 5

Medications for inhibition of peripheral adrenergic effects

Answer 5

1. Propanolol
2. Esmolol
3. Reserpine
4. Guanethidine

PERG

inhibition of peripheral adrenergic effects

Question 6

Dose of Propanolol

Answer 6

0.5-1mg TIV over 10 mins
then
1-2mg every few hrs to effect

OR

60-80mg PO q4

inhibition of peripheral adrenergic effects

For reactive airway diseases: Atenolol, Metoprolol, CCB

Question 7

Dose of Esmolol

Answer 7

250-500 micrograms/kg IV loading
then
50-100micrograms/kg/min titrated to effect

inhibition of peripheral adrenergic effects

Question 8

Dose of Reserpine

Answer 8

1mg test dose
then
2.5 to 5.0 mg IM q4-6

inhibition of peripheral adrenergic effects

consider using if B-blocker is contraindicated BUT avoid in congestive heart failure or hypotension

Question 9

Dose of Guanethidine

Answer 9

30-40mg PO q6

inhibition of peripheral adrenergic effects

consider using if B-blocker is contraindicated BUT avoid in congestive heart failure or hypotension

Question 10

Drugs for inhibition of Thyroid Hormone Synthesis (2)

Answer 10

1. Methimazole
2. PTU

Question 11

Dose of Methimazole

Answer 11

20mg q6 PO

Drugs for inhibition of Thyroid Hormone Synthesis

AVOID IN PREGNANCY; CAT D; TERATOGENIC IN 1st Trimester

Question 12

Dose of PTU

Answer 12

LD: 500 to 1000mg PO
then
250mg q4

Drugs for inhibition of Thyroid Hormone Synthesis

Given in the 1st trimester
Rare SE: Severe hepatic dysfunction, hepatic failure in mother and fetus

Question 13

Drugs of inhibition of Thyroid Hormone synthesis (5)

Answer 13

1. Lugol solution
2. Potassium iodide
3. IV iopanoic acid
4. Ipodate
5. Lithium carbonate

Question 14

When do you give drugs for inhibition of thyroid hormone synthesis

Answer 14

at least 1hr after step 3

Question 15

Dose of Lugol solution

Answer 15

8-10 drops PO q6-8

When do you give drugs for inhibition of thyroid hormone synthesis

Question 16

Dose of SSKI

Potassium iodide

Answer 16

5 drops PO q6

0.25ml or 250mg

Question 17

Drug for inhibition of thyroid hormone release that is pregnancy category C

Answer 17

Iopanoic acid

Question 18

Espscially useful with thyroiditis or thyroid hormone overdose

Answer 18

Ipodate / Oragrafin

Question 19

Drug for inhibition of thyroid hormone release that is contraindicated for pregnant

Answer 19

Litium carbonate

Question 20

Drug and dose for preventing peripheral conversion of T4 to T3 (2)

Answer 20

1. Hydrocortisone 300mg TIV initially then 100mg q8
2. Dexamethasone 2mg TIV q6

Question 21

Drug for prevention of free thyroid hormone reabsorption

Answer 21

Cholestyramine 4g q6