**3.2 Etiology**

The thyroid storm commonly occurs in Graves' disease, toxic adenoma, and the multi-nodular toxic goiter. The exact etiology of thyroid storm is not known, there will be always a precipitating factor and the extremes of stress concurrent, systemic acute illness such as sepsis or increasing incidence with emergency surgery.

### **3.3 Clinical presentation**

Patient thyroid storm will have exaggerated hyperthyroidism signs and symptoms. Fever, tachycardia, tachyarrhythmias and heart failure, central nervous system (CNS), and Gastrointestinal (GI) manifestations are frequent. The CNS manifestations will be agitation, delirium, anxiety, and coma. The GI symptoms are nausea, vomiting, diarrhea, intestinal obstruction, and hepatic failure. Examinations will reveal orbitopathy, goiter, hand tremors, moist and warm skin, and jaundice [6].

Common signs and symptoms are summarized in the following **Table 2**.


**Table 2.**

*Common signs and symptoms for thyrotoxicosis and thyroid storm.*

#### **3.4 Diagnosis**

Thyroid storm should be suspected from clinical presentations in hyperthyroidism or suspected hyperthyroidism patients. Laboratory workup will show low thyroid stimulating hormone (TSH) and high T3/T4 levels. Patient will have hyperglycemia, hypercalcemia, leukocytosis, and abnormal liver function test. Various scoring systems for the diagnosis of thyroid storm are described in **Tables 3** and **4** [8].

According to the Japanese thyroid association (JTA), it is essential to diagnose thyroid storm by the elevated free T3 or T4 with one CNS manifestation and pulmonary


*Score of 25 to 45 may indicate impending thyroid storm. Score less than 25 makes the diagnosis unlikely.*

#### **Table 3.**

*Burch–Wartofsky point scale (BWPS) scoring systems for thyroid storm.*

#### Elevated T3/T4

Fever (38 ©C/100.4 °F or greater)

Central nervous system (CNS) manifestation will be restlessness, delirium, psychosis/mental aberration, lethargy/somnolence, coma

Heart rate (130/min or higher)

Congestive heart failure (pulmonary edema to cardiogenic shock)

GI Manifestation (from vomiting to jaundice)

#### **Table 4.**

*JTA scoring [7].*

#### **Figure 2.** *POCUS showing hypervascular left lobe of thyroid gland.*

symptoms along with fever, congestive heart failure (CHF), and tachycardia or combination of three features fever, GI/hepatic and congestive heart failure (CHF) or tachycardia. The JTA scoring system is more specific in diagnosis of thyroid storm.

Chest X-ray may show pulmonary congestion or pulmonary edema or cardiomegaly. ECG should be done which may reveal sinus tachycardia or tachyarrhythmia. Bedside POCUS may reveal a hypervascular thyroid gland (**Figure 2**). Patient may be breathless or short of breath and or hypotensive.

#### **3.5 Management**

One should not waste golden time in waiting for laboratory results, as thyroid storm is a medical emergency. Thyroid storm patients may present in shock, we should follow airway, breathing, circulation, deficit and exposer (ABCDE) approach and manage either cardiogenic or other dehydration causing hypovolemic shock in these patients. We should have continuous supportive management with advanced hemodynamic monitoring with intravenous fluids, core body temperature management, if required vasopressor and inotropes. These patients may have tachyarrhythmias and should be managed as per acute life support (ALS) protocol. These patients with thyroid storm need intensive care therapy unit admission and management.

The specific management strategies of thyroid storm are described in the following points.


After ABCDE of supportive care, a beta-blocker should be started. Usually, propranolol 40–80 mg every 4 to 6 hours is administered.

PTU loading dose up to 1000 mg and followed by 250 mg every 4 hours or methimazole can be administered. PTU is preferred as it also has additional action of blocking peripheral conversion of T4 to T3. After 1 hour of PTU administration, 5 drops of supersaturated potassium iodide (SSKI) should be given per oral and repeat 6 hourly. This will prevent increase in synthesis of thyroid hormone due to iodine administration [9]. Hydrocortisone or dexamethasone, 100 mg intravenously and 2 mg Q 6 hourly respectively should also start. Cholestyramine 4 grams, 3 to 4 times will prevent enterohepatic recycling of thyroid hormones. Aspirin increases thyroid hormone levels and should be avoided in thyroid storm in these patients.

PTU decreases T3 by 45% in initial 24 hours of treatment. The methimazole causes more rapid normalization of T3 after weeks of treatment. Hence after initial stabilization, PTU should be changed to methimazole, if patient cannot take these medications orally can be given, and liquid preparation of the medications can be administered rectally. Patients with Graves' disease should be pretreated with betablocker, iodine therapy, and antithyroid medication before undergoing surgical intervention.

These medications are contraindicated due to allergy, thyroidectomy is required after treatment with Beta-blocker, steroids, cholestyramine, and iodine administration. The plasmapheresis should be the last resort if above measures fail [10].

#### **4. Morbidity and mortality**

Thyroid storm is fatal if not treated, usually heart failure, arrhythmias, or multiorgan failure leads to the death. If treatment starts, patients improve within 24 hours. The advanced age, neurological dysfunction upon admission, failure or delayed use of antithyroid medications or beta-blockers, requiring dialysis or mechanical ventilator increases the risk of death with poor prognosis [11].
