Management requires intensive monitoring and supportive care, identification and treatment of the precipitating cause, and measures that reduce thyroid hormone synthesis.
MMI 4-6hrs, PTU1.5hr PTU inhibit T4->T3
the propylthiouracil inhibitory action on T4 T3 conversion makes it the antithyroid drug of choice. Wolff-Chaikoff effect (the delay allows the antithyroid drug to prevent the excess iodine from being incorporated into new hormone). Although other -adrenergic blockers can be used, high doses of propranolol decrease T4 T3 conversion, and the doses can be easily adjusted.
Thyroid Storm 實習醫師 陳柏達
Thyrotoxicosis and Thyroid Storm
Bindu Nayak, MD, Kenneth Burman, MD, Endocrinol Metab Clin N Am 35(2006) 663-686
Harrison's Principles of Internal Medicine
Perioperative management of the thyrotoxic patient
Roy W. Langley, MD, Henry B. Burch, MD, Endocrinol Metab Clin N Am 32 (2003) 519–534
Patients with thyroid storm have relatively higher levels of free thyroid hormones(THs) than patients with uncomplicated thyrotoxicosis, even though total TH levels may not be increased.
Adrenergic receptor activation is a hypothesis. Sympathetic nerves innervate the thyroid gland, and catecholamines stimulate TH synthesis. In turn, increased THs increase the density of beta-adrenergic receptors, thereby enhancing the effect of catecholamines.
Another theory suggests a rapid rise of hormone levels as the pathogenic source. A drop in binding protein levels, which may occur postoperatively, might cause a sudden rise in free hormone levels. In addition, hormone levels may rise rapidly when the gland is manipulated during surgery, during vigorous palpation during examination, or from damaged follicles following RAI therapy.
Other proposed theories include alterations in tissue tolerance to THs, the presence of a unique catecholaminelike substance in thyrotoxicosis, and a direct sympathomimetic effect of TH as a result of its structural similarity to catecholamines.
A score of 45 or more is highly suggestive of thyroid storm; a score of 25 to 44 supports the diagnosis; and a score below 25 makes thyroid storm unlikely. Adapted from Burch, HB, Wartofsky, L, Endocrinol Metab Clin North Am 1993; 22:263.
Large doses of propylthiouracil (600mg loading dose and 200 to 300 mg every 6 h) orally or per rectum;
One hour after the first dose of propylthiouracil, stable iodide is given to block thyroid hormone synthesis via the Wolff-Chaikoff effect : saturated solution of potassium iodide (5 drops SSKI every 6 h), or ipodate or iopanoic acid (0.5 mg every 12 h), may be given orally. (Sodium iodide, 0.25 g intravenously every 6 h is an alternative but is not generally available.)
Dr. Plummer Physician, scientist, architect and engineer, Dr. Henry Plummer has rightly been called "a diversified genius." E.B. Astwood, May 8, 1943: Treatment of hyperthyroidism with thiourea and thiouracil.
Thyroid Storm – operation consideration Absolute indications Failed medical therapy Severe reaction to antithyroidal drugs and not a candidate for radioablation therapy Persistent thyrotoxicosis despite maximum antithyroidal drug therapy or repeated radioablation treatments Underlying thyroid cancer Suspicious or malignant nodules on FNA Relative Indications Symptomatic goiters Pregnancy Severe Graves’ ophthalmopathy Refractory thyroiditis Amiodarone related Nonremitting subacute thyroiditis Toxic adenoma Rapid control of symptoms required Aversion to antithyroidal drugs and radioablation therapy