Thyroid emergencies: thyrotoxicosis, and thyroid storm

Question 1

Airway

Answer 1

Question 2

Breathing

Answer 2

Look: increased respiratory effort, or rate
Listen: vesicular sounds
Feel: chest expansion, percussion, tracheal deviation

RR, O2

CXR

Question 3

Circulation

Answer 3

Look: sweaty, diaphoretic
Listen: S1+2+0
Feel: apex beat, CRT, pulses

HR (increased)
BP

• ECG
• Bloods: FBC, TFTs, LFTs, UEs, CRP, VBG, T3, T4, TSH
• Plasma renin, aldosterone
• Plasma metanephrines/ 24 hr urinary collection

Management:
* IV access
* IV fluids
* sedate if necessary (eg chlorpomazine 50mg PO/IM)
* Propranolol 60mg 4-6 hourly PO (max IV dose 1mg over 10 mins) - IV esmolol if reduced CO
* Consider diltiazem if beta blockers CI
* High dose digoxin to slow heart rate
* Antithryoid drugs: carbimazole 15-25mg/6hours PO (or via NGT)
* Lugol’s Iodine 0.3 mL/8h PO well diluted in water for 7-10 days to block thryroid
* Hydrocortisone 100mg/6h IV or dexa 2mg / 6h PO (to prevent peripheral conversion of T4 to T3)

If infection: co-amoxiclav 1.2/8h IV

Question 4

D,E

Answer 4

regular

high temp
low GCS
Delirium
LoS

Thyroid exam
Thyroid technitium scan
USS