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Thyroid storm (thyrotoxic crisis, thyrotoxicosis)
Thyroid storm (thyrotoxic crisis) is a form of severe hyperthyroidism, usually of abrupt
onset. Untreated it is almost always fatal, but with proper treatment the mortality rate is
reduced substantially. The patient with thyroid storm or crisis is critically ill and requires
astute observation and aggressive and supportive nursing care during and after the acute
stage of illness.
Clinical manifestations
Thyroid storm is characterized by:
• High fever (hyperpyrexia) above 101.3°F ( 38.5°C )
• Extreme tachycardia (more than 130 beats/min)
• Exaggerated symptoms of hyperthyroidism with disturbances of a major system—for example, GI (weight loss, diarrhea, abdominal pain), or cardiovascular (edema, chest pain,
dyspnea, palpitations)
• Altered neurologic or mental state, which frequently appears as delirium psychosis, somnolence, or coma
Life-threatening thyroid storm is usually precipitated by stress, such as injury,
infection, thyroid and nonthyroid surgery, tooth extraction, insulin reaction, diabetic acidosis, pregnancy, digitalis intoxication, abrupt withdrawal of antithyroid medications, extreme
emotional stress, or vigorous palpation of the thyroid. These factors can precipitate thyroid
storm in the partially controlled or completely untreated patient with hyperthyroidism. Current methods of diagnosis and treatment for hyperthyroidism have greatly decreased the
incidence of thyroid storm, making it uncommon today.
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Management
Immediate objectives are reduction of body temperature and heart rate and prevention of
vascular collapse. Measures to accomplish these objectives include:
• A cooling blanket, ice packs, a cool environment, hydrocortisone, and acetaminophen
(Tylenol). Salicylates, such as aspirin, aren’t used because they displace thyroid hormone
from binding proteins and worsen the hypermetabolism.
• Humidified oxygen is administered to improve tissue oxygenation and meet the high metabolic demands. Arterial blood gas levels or pulse oximetry may be used to monitor respiratory status.
• Intravenous fluids containing dextrose are administered to replace liver glycogen stores
that have been decreased in the hyperthyroid patient.
• PTU or methimazole is administered to impede formation of thyroid hormone and block
conversion of T4 to T3, the more active form of thyroid hormone.
• Hydrocortisone is prescribed to treat shock or adrenal insufficiency.
• Iodine is administered to decrease output of T4 from the thyroid gland. For cardiac problems such as atrial fibrillation, dysrhythmias, and heart failure, sympatholytic agents may be
administered. Propranolol, combined with digitalis, has been effective in reducing severe
cardiac symptoms
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Source: Brunner and Suddarth’s Medical-Surgical Nursing, 11th ed., SC Smeltzer
and BG Bare (eds), Lippincott Williams & Wilkins, 2006.
Take5 ©2006 Lippincott Williams & Wilkins
Brought to you by Nursing2006
Hyperthyroidism
Hyperthyroidism is the second most prevalent endocrine disorder, after
diabetes mellitus. Graves’ disease, the most common type of hyperthyroidism, results from an excessive output of thyroid hormones
caused by abnormal stimulation of the thyroid gland by circulating immunoglobulins. It affects women eight times more frequently than men,
with onset usually between the second and fourth decades. It may appear after an emotional shock, stress, or an infection, but the exact significance of these relationships is not understood. Other common causes
of hyperthyroidism include thyroiditis and excessive ingestion of thyroid hormone.
Clinical manifestations
Patients with well-developed hyperthyroidism exhibit a characteristic
group of signs and symptoms (sometimes referred to as thyrotoxicosis).
The presenting symptom is often nervousness. These patients are often
emotionally hyperexcitable, irritable, and apprehensive; they can’t sit
quietly; they suffer from palpitations; and their pulse is abnormally
rapid at rest as well as on exertion. They tolerate heat poorly and perspire unusually freely. The skin is flushed continuously, with a characteristic salmon color, and is likely to be warm, soft, and moist. Elderly
patients, however, may report dry skin and diffuse pruritus. A fine
tremor of the hands may be
Causes of primary
observed. Patients may exhyperthyroidism
hibit exophthalmos (bulging
Toxic diffuse goiter (Graves’ disease)
Toxic adenoma
eyes), which produces a starToxic multinodular goiter
tled facial expression.
Painful subacute thyroiditis
Other manifestations
Subacute or silent thyroiditis
include
an
increased appetite
Excessive iodine intake
and dietary intake, progresExcessive thyroid hormone replacesive weight loss, abnormal
ment therapy
muscular fatigability and weakness (difficulty in climbing stairs and rising
from a chair), amenorrhea, and changes in bowel function. The pulse rate
ranges constantly between 90 and 160 beats/min; the systolic, but characteristically not the diastolic, blood pressure is elevated; atrial fibrillation may occur; and cardiac decompensation in the
form of heart failure
is common, especially in elderly patients. Osteoporosis
and fracture are also
associated with hyperthyroidism.
Cardiac
effects may include
sinus tachycardia or
dysrhythmias, increased pulse presThe thyroid gland and surrounding structures.
sure, and palpitations; it has been suggested that these changes may be related to increased
sensitivity to catecholamines or to changes in neurotransmitter turnover. Myocardial hypertrophy and heart failure may occur if the hyperthyroidism is severe and untreated.
The course of the disease may be mild, characterized by remissions
and exacerbations and terminating with spontaneous recovery in a few months
or years. Conversely, it may progress relentlessly, with the untreated person
becoming emaciated, intensely nervous, delirious, and even disoriented; eventually, the heart fails.
Symptoms of hyperthyroidism may occur with the release of excessive amounts of thyroid hormone as a result of inflammation after irradiation
Lab findings with hyperthyroidism
TSH
FT3
FT4
Overt hyperthyroidism
Decreased
Increased
Increased/
unchanged
Subclinical hyperthyroidism
Decreased
Normal
Normal
of the thyroid or destruction of thyroid tissue by tumor. Such
symptoms may also occur with excessive administration of thyroid hormone for treatment of hypothyroidism. Long-standing
use of thyroid hormone in the absence of close monitoring may
be a cause of symptoms of hyperthyroidism. It is also likely to
result in premature osteoporosis, particularly in women.
Assessment and diagnostic findings
The thyroid gland invariably is enlarged to some extent. It is soft
and may pulsate; a thrill often can be palpated, and a bruit is
heard over the thyroid arteries. These are signs of greatly increased blood flow through the thyroid gland. In advanced cases,
the diagnosis is made on the basis of the symptoms and an increase in serum T4 and an increased I or I uptake by the thyroid in excess of 50%.
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Gerontologic considerations
Elderly patients commonly present with vague and nonspecific
signs and symptoms, making disorders hard to detect. Symptoms
such as tachycardia, fatigue, mental confusion, weight loss,
change in bowel habits, and depression can be attributed to age
and other illnesses common to elderly people. In addition, the
patient may report cardiovascular symptoms and difficulty
climbing stairs or rising from a chair because of muscle weakness. New or worsening heart failure or angina is more likely to
occur in elderly than in younger patients. The elderly patient may
experience a single manifestation, such as atrial fibrillation, anorexia, or weight loss. These signs and symptoms may mask the
underlying thyroid disease.