Thyroid Storm?

[Happy-ER-RN]

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.

[sirI, MSN, APRN, NP]

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).

I think you have done an admirable job protecting privacy. I just don't think you need to go and try to ask around for more info, unless you just want too.

I am sure you will practice the utmost in trying to protect privacy.

Not a violation here........be careful of what the staff at your facility might think you are doing........educational purposes?

[MistyDawnRN06, BSN, RN]

Having experienced a thyroid storm, it sounds like your patient was having one to me. It was certainly a good differential diagnosis since you knew she had Grave's.

The thing about thyroid storms is that they're frequently misdiagnosed. And I've found that most MD's do not understand thyroid disorders. The Doc may not have suspected this diagnosis. Symptoms of a storm are soooo variable, that it makes it difficult to diagnose - scary since it can be FATAL!

Temps can vary from 100 to 106, GI symptoms from nausea/vomiting/diarrhea, severe tachycardia, agitation, delerium, shock, etc. Labs just aide in diagnosis (they're not totally reliable).

It would have been interesting to see if thyroid suppression helped with her symptoms. Too bad the Doc didn't think of it. Next time you might want to politely ask the Doc if he thought that PTU would help (make him think it's his idea).

Of course it could have been other things, but with a history of Grave's, I think you were on the right track.

[Leelee2]

Keep in mind that some patients temp's run low to begin with, so the temp may only be slightly elevated.

The RUQ pain was probably the liver being irritated by the graves disease being active. From all the other symptoms mentioned, it sounds like a thyroid storm. With the thyroid levels being that off, she should have been treated with anti-thyroid medication.

[JKL33]

I think you should feel free to go to your Clinical Support person (or someone authorized to work in that role) and request that they review this case with you. There is NO HIPAA violation associated with this type of staff education. Do NOT look at EMR yourself or call the unit. Go to the appropriate person and explain just what you have told us here. If you are in a place where everything under the sun is a "HIPAA violation" and your professional education is not supported....to the DETRIMENT of future patients, you might consider looking around for a place that will support you more as you grow in your role as an RN.

Some places are providing official feedback regarding these cases, as a means of having the members of the team who stabilized the patient know what the outcome was, without having people cry foul about HIPAA violations constantly. I think this is a very good trend we would be wise to support. We NEED to learn from these types of experiences so that we can serve the next patient to the best of our abilities.