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Thyroid Storm

Chris Bowen T4 Keyword Presentation April 29th 2011 Anesthesia. Thyroid Storm. Your 6 AM is ready. 44 y/o patient with Graves’ Dx Recently cleared for total thyroidectomy The surgical H&P: AF VSS WNL RRR no m/r/g CTAB. Upon exam. Vitals: 101.9 167 153/86 26 Agitation

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Thyroid Storm

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  1. Chris Bowen T4 Keyword Presentation April 29th 2011 Anesthesia Thyroid Storm

  2. Your 6 AM is ready • 44 y/o patient with Graves’ Dx • Recently cleared for total thyroidectomy • The surgical H&P: • AF VSS WNL RRR no m/r/g CTAB

  3. Upon exam • Vitals: 101.9 167 153/86 26 • Agitation • Scleralicterus • Bilateral crackles with expiratory wheezing • Palpitations • Mild diaphoresis and nausea without emesis • No obstruction of airway 2 /2 goiter

  4. Thyroid Storm • Thyrotoxic vs. Thyroid Storm • Life-threatening complication • Mortality with Tx 8% or below • Most cases occur post-op • Within 6-18 hrs • Why? Pre-op Tx necessary? • Si/Sx varied but consider… • Hyperdynamic Metabolism • SITT DD are common triggers • Burch and Wartofsky Score • ≥ 45 highly suggestive of thyroid storm • ≤ 25 thyroid storm unlikely

  5. Burch and wartofskypoint system • Temp: • 99-99.9 5 points • 100-100.9 10 points • ≥ 104.0 30 points • Tachycardia • 90-109 5 points • 110-119 10 points • 120-129 15 points • ≥140 25 points • A. Fib • Absent 0 points • Present 10 points • Precipitating Event • Absent 0 points • Present 10 points • CHF • Absent 0 points • Mild (pedal edema) 5 points • Moderate (bb rales) 10 points • Severe(pulm edema) 15 points • CNS • Absent 0 points • Mild 10 points • Moderate 20 points • Severe 30 points • GI-Hepatic • Absent 0 points • Moderate 10 points • Severe 20 points

  6. Management • Pre-op euthyroidism • Goiter? • Patients with tachycardia and HTN  consider cancellation • Iodide • Sodium Iodide, Iopanoic acid, Lugol’s solution • Block the release of hormone • Wolff-Chaikoff effect • Beta-Blocker • Cortisol • Adrenal function? • Thionamides • PTU favored for decrease in peripheral conversion • Cholestyramine • Temp control • Hydration • With or without glucose?

  7. Post-op complications • Nerve damage • Superior Laryngeal • Motor to Cricothyroid mm.  aspiration • Recurrent Laryngeal • Everything laryngeal except Cricothyroid  Hoarseness, stridor, total airway obstruction • Hypoparathyroidism • Laryngospasm • Hypothyroidism • Tracheal Compression

  8. Thank You

  9. References • “Big Blue” • Nayak B., Burman K.: Thyrotoxicosis and Thyroid Storm. Endocrinology and Metabolism Clinics 35. (4): 2006. • Pearce E., Braverman L.: Hyperthyroidism: advantages and disadvantages of medical therapy. Surgical Clinics of North America 84. (3): 2004. • Franklyn JA.: The Management of Hyperthyroidism. New England Journal of Medicine 330 (24): 1731-8. 1994 abstract. • Burch H.B., Wartofsky L.: Life-threatening thyrotoxicosis. Thyroid Storm. Endocrinology and Metabolism Clinics of North America 22: 263-277. 1993. abstract.

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