Thyroid Storm?

carachel2 · Aug 24, 2005

What were other assessment findings ? Posterior breath sounds ? Any edema ?

EricTAMUCC-BSN, BSN, RN · Aug 24, 2005

It would have been interesting to see if the PTU helped. Looks like that was good experience.

RoadRunner · Aug 24, 2005

Thyroïd storms are a rare complication and can lead to multiple organ failure.

The only time I had to care for a patient with this syndrome, she developped heart failure so bad she had to had a heart transplant... In a 24 hours period, she "coded" two times, was transfered to a transplant facility urgently waiting for a heart and was finally transplanted with a new heart! Let's just say it was the fullest 24 hours of her life...

I don't remember her T4 or TSH levels but I think the clinical evaluation prevails over the lab results. A case of "treat the clinic, not the labs".

Do you know if she pulled throught?

Editorial Team / Admin · Aug 24, 2005

Last week a 30 yo female came in with RUQ pain. She looked shaky and pale. I hook her up to the monitor and her pulse is 180, BP 180/100. Hmmmm...that's not good, so my counterpart is starting an IV and I get her history--she has Graves Disease. As a new grad, I thought, hmmmm, I remember reading about this, crap, she is in thyroid storm. So I run to get the Doc. Well, we gave adenocard, metropolol (IV and PO eventually), cardizem over the course of an hour or more and she was getting worse, pulse up to 210. I kept thinking why don't we give her something for her thyroid--PTU, or whatever, but who am I to state the seemingly obvious as a new grad.
I gave her 2 mg of propranolol very slow IVP, with no change, and repeat the dose 20 minutes later per orders. Well after about 3 minutes she starts to vomit, then her pressure drops to 80/40 and pulse down to 40! We gave her a little bit of Atropine and started a Dopamine drip, NOT WORKING, she looks like sh** and her pulse and pressure kept dropping. Maybe the PO metropolol hit her... I don't know. I have never given a lot of these drugs before so I am wreck at this point--a nurse was helping and the doc was at the bedside most the time, but still! We start to bolus her and turn her on her head and all that, then she gets short of breath and her O2 starts dropping. The doc thought maybe it's a PE so we whisk her away to CT where they discover she has fluid in her lungs and her heart is large.
We ended up putting her on Bipap and got her pressure and pulse up a little before we sent her to ICU. (after we dumped 3 liters in to get her pressure up--this was before the SOB started though)
So, have any of you ever cared for a patiet in thyroid storm? The doctor said this is not thyroid storm. Her T4 was insanely high but her TSH nonexistent. I got home and looked it up and thyroid storm causes CHF eventually. That just has to be what happened. Why didn't we give her PTU? Why did she bottom out all of a sudden when we had waited in between all the doses? Thought this might be a better learning experience if I had some more input.

A cardinal sign of Thyroid storm is hyperpyrexia.....temp = or >105 F. This is THE most reliable finding. Hypertension is common, but, the patient can be normo or hypotensive as well. Atril fib is very common. Usually very diphoretic. Dehydration secondary to GI losses and diaphoresis. Acute behavioral changes.

There is no evidence that increased production of T4 causes thyroid storm. The free T4 will be markedly elevated and TSH markedly low. Labs alone cannot dx storm.

A good differential dx is CHF with pulmonary edema, DM, septic shock, as well as others.

Hope this helps.

Editorial Team / Admin · Aug 24, 2005

According to my Epocrates program, PTU dose is 200-300mg PO qid if thyroid storm.

How is she doing? It's harder to get a diff. diagnosis with so much going on. Good for you, for thinking of the PTU!

My son was on PTU for 2 1/2 yr, for Hashimoto's thyroiditis, diagnosed when he was 9 yo. I didn't realized till I just now looked it up, that it is given for thyroid storm as well, different dosage of course. ------------ D:)

funinsun · Aug 25, 2005

I have just experienced something similar though not in the hospital a few weeks ago. A very dear friend of mine and second 'mother' about 50 yo unexpectedly died of a heart attack while at the ATM.. She had no health problems except Graves Disease and the complications from that.. (exopthalamus, very energetic etc.) She periodically went off of her medication (PTU) because it made her feel 'down'.. I don't know if she was on her meds at the time, but apparently suffered a massive MI.. The doctors blamed it on stress (she was in a stressful situation at the moment but was overall a calm person) but made no mention of the Graves being a factor.. Unfortunately I didn't talk to her that day to know if she was pre-'thyroid storm' or if that even predisopses you to heart problems.. I'm thinking her heart rate probably went so high that she went into some arrthymia.. (the medic's didn't arrive for 15 minutes after 911 call)

Anyway, a bad situation, but do you think the thyroid problem could have contributed?

Editorial Team / Admin · Aug 25, 2005

I have just experienced something similar though not in the hospital a few weeks ago. A very dear friend of mine and second 'mother' about 50 yo unexpectedly died of a heart attack while at the ATM.. She had no health problems except Graves Disease and the complications from that.. (exopthalamus, very energetic etc.) She periodically went off of her medication (PTU) because it made her feel 'down'.. I don't know if she was on her meds at the time, but apparently suffered a massive MI.. The doctors blamed it on stress (she was in a stressful situation at the moment but was overall a calm person) but made no mention of the Graves being a factor.. Unfortunately I didn't talk to her that day to know if she was pre-'thyroid storm' or if that even predisopses you to heart problems.. I'm thinking her heart rate probably went so high that she went into some arrthymia.. (the medic's didn't arrive for 15 minutes after 911 call)
Anyway, a bad situation, but do you think the thyroid problem could have contributed?

I am so sorry about your friend.

It is possible. Remember that hyperpyrexia (= or > 105 F) is THE most reliable finding during thyroid storm. It may or may not be the cause of your friends death.

Again, I am so sorry.

stidget99 · Aug 25, 2005

Brings back memories.....

I had Grave's Disease while in my first semester of nursing school. I had dozens of thyroid storms. My symptoms were: tachy heart, inability to talk, inability to walk, diaphoresis. I had no clue what was happening. It was a long time before I learned that I was at risk for dying w/ each one of these storms. Once had one while caring for a pt on the floor. He thought I was drunk and requested to have me removed from the floor. I was escorted out the front door and eventually was told to not come back to school. They didn't bother to even ask what was wrong or even assess to see if I was ok. I later had to provide medial notes in order to get back into the program.

My pulse was chronically tachy. It was so fast that when I counted it, I had to count by 2's (generally up over 200 bpm). The two times that I did call EMS, they transported me to the ER. And by the time I arrived, my symptoms had gone and they released me. I also got the impression from them that I wasted their time.

It's very scary to think about the "what-ifs". I had no clue that I could've gone into heart failure and/or arrested. It would be interesting to see, later in my life, if I develop cardiac problems r/t all of these thyroid storms.

Happy-ER-RN, RN · Aug 26, 2005

Thanks for all the replies. Her temp was 100.9. I can't remember if I even listened to her lungs because I was so panicked about her initial assessment finding I just got the Dr. I never found out anything about the RUQ pain, maybe she had a gallbladder issue on top of the thyroid problem. I haven't heard how she is doing yet. I have not yet figured out how I can find out without a Hippa violation. Sometimes the charge nurse knows the info but I don't know if I am allowed to call the ICU and try to find out myself, I doubt it. I am going to try to find out next time I work and I'll let you know if I find out anyting interesting.

Editorial Team / Admin · Aug 26, 2005

Thanks for all the replies. Her temp was 100.9. I can't remember if I even listened to her lungs because I was so panicked about her initial assessment finding I just got the Dr. I never found out anything about the RUQ pain, maybe she had a gallbladder issue on top of the thyroid problem. I haven't heard how she is doing yet. I have not yet figured out how I can find out without a Hippa violation. Sometimes the charge nurse knows the info but I don't know if I am allowed to call the ICU and try to find out myself, I doubt it. I am going to try to find out next time I work and I'll let you know if I find out anyting interesting.

You do not need to try and find out any more information. You certainly do not want to run the risk of breech of confidentiality.

I think that you presented a good picture of what happened.

Thank you for this clinical picture. I believe you did a great job.

Happy-ER-RN, RN · Aug 27, 2005

Hmmm...Is that really a violation to find out for educational purposes? I guess it would depend on if I had the pts permission from the ICU to share with me. I understand it would be a violation to post things had I put any identifying info (I altered that drastically before I posted the first post though).