Thyroid Storm

: Audience: This simulation is designed to educate emergency medicine residents and medical students on the recognition and management for thyroid storm. Discussion: This is a cost-effective method for reviewing thyroid storm. Learners had a wide range of narrow versus broad differentials, as well as comfort level with treatment. Having the pharmacist unavailable to answer their questions caused them to rely on alternative sources of knowledge, typically, their cell phones. Our main take-away is to continue providing visual stimuli to enhance a physical exam in order to bolster psychological buy-in.


Linked objectives and methods:
Thyroid storm is an uncommon ED presentation, and many of the symptoms are consistent with much more common ED diagnoses. The most important tool for diagnosis of this lifethreatening condition is having a high clinical suspicion. This simulation scenario allows learners to review the patient presentation, highlights the importance of the prehospital history and of obtaining pertinent past medical history and a current medication list. Learners will have the opportunity to perform initial assessment and provide appropriate resuscitation of a critically ill patient (objective 1). They will work through a differential diagnosis for life-threatening causes of altered mental status and order appropriate tests and workup to narrow the differential (objective 2). Learners will need to identify possible underlying etiologies (objective 3) and initiate treatment (objective 4). Afterwards, there will be discussion about the etiology, pathophysiology, and mechanism of action of the pharmacologic treatment of thyroid storm (objectives 1-4).

Recommended pre-reading for instructor:
We recommend that instructors become familiar with the 2016 American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism. 1 Other suggested reading includes the materials listed below under "References/suggestions for further reading."

Results and tips for successful implementation:
This simulation was written to be performed as a high-fidelity simulation scenario but may also be used as a mock oral board case. We conducted this scenario approximately twelve times for fifty emergency medicine residents broken into groups of four during August-September 2018. The residents voiced appreciation at seeing a photograph of the patient's face at the beginning of the case, as the ophthalmopathy was difficult to reproduce on the mannequin. Depending on the desired level of autonomy, faculty may inform learners their pharmacist is at lunch, so they are unable to ask them recommended doses and instead must look them up on smart phones or provided computers. We typically do not allow pharmacists in simulation cases to make clinical suggestions, but may provide dosages for rarely-used medications.

Objectives:
By the end of this simulation session and debriefing, the learner will be able to:

Case Description & Diagnosis (short synopsis):
Patient is a 75-year-old female is brought in by emergency medical services (EMS) with complaint of agitation. A bystander in grocery store called 911 because the patient was agitated, yelling and swearing at bystanders. Patient is found to be in atrial fibrillation with rapid ventricular response and a low-grade fever. If requested, EMS or the nurse will provide the team with the patient's purse, which contains her home medications. Her physical exam is remarkable for a thyroid goiter and bilateral proptosis. Labs are remarkable for leukocytosis, a low TSH (thyroid-stimulating hormone), and an elevated free T4. Learners should suspect thyroid storm and administer propranolol, a thioamide, glucocorticoids, and arrange for iodine to be administered an hour after thioamide has been given. If beta-blockers are not ordered, the patient will become more tachycardic. If iodine is administered less than an hour after thioamide is administered, the patient will become more agitated and tachycardic until additional beta-blockade is administered. Team should have a low threshold to administer broad-spectrum antibiotics to cover possible underlying infection. The patient should then be admitted to the intensive care unit. Background and brief information: Patient is a 75-year-old female brought in by EMS for agitation. A bystander in a grocery store called 911 because the patient was agitated, yelling and swearing at bystanders. Initial presentation: Patient is a 75-year-old female who appears her stated age, but appears disheveled and diaphoretic. She is intermittently yelling at the nurse and anyone who comes near her bed.

Equipment or Props
How the scenario unfolds: Participants should perform a complete physical exam, including skin, back, and neurologic evaluations. If they ask about home medications, nursing can provide the team with the patient's purse, which includes her home medications. Participants should have a low threshold to evaluate and treat for other causes of encephalopathy or potential precipitants for her thyroid storm, which may include performing a lumbar puncture. The patient will initially be too agitated to have this performed and will require medication to do so. Once beta-blockade is ordered, her tachycardia will improve. If iodine is ordered less than an hour after thioamide is administered, she will become more agitated and tachycardic until given additional beta-blockade. Case should be discussed with endocrinology and the intensivist, then admitted to the intensive care unit (ICU).

Thyroid Storm Pearls
• Thyroid storm is a not a diagnosis which ED providers will commonly encounter; however, it is important to be able to recognize quickly because the condition can be life-threatening. About 1%-2% of patients with hyperthyroidism will develop thyroid storm, but often the etiology of the progression to storm is unclear. 1 • A focused history should be obtained, including use of amiodarone, inappropriate hormone ingestion for weight loss, recent surgery, or radioiodine therapy. • The most common presenting signs and symptoms include hyperpyrexia, tachycardia, CNS dysfunction, and GI manifestations. 2-4 • The workup should include tests to evaluate for an underlying etiology, such as infection, heat related illness, or toxidromes. These diagnostic studies may include blood cultures, urinalysis, a chest x-ray, and/or CT head. • Initial pharmacologic treatment includes a thioamide, a non-selective beta blocker, as well as glucocorticoid. The American Thyroid Association recommends propylthiouracil (PTU) as the first-choice thioamide due to its additional benefit of blocking peripheral conversion of T4 to T3; however, methimazole is also an acceptable option. 3 PTU is administered as a 600mg oral loading dose followed by 250mg every 4 hours. 5 • The most common non-selective beta blocker described in the literature is propranolol with a dose of either 1-2mg IV q15 minutes or 60-120 mg PO q6 hours. 2, 5 • Glucocorticoids are used to block peripheral conversion of T4 to T3. They are given in the form of stress-dose steroids; 300mg hydrocortisone IV loading dose, followed by 100mg q8 hours. 5 This also serves to counteract adrenal insufficiency in the shock state. 2,4 • Iodine is also included in the treatment; however, it is important to note that one must wait at least 1 hour after administration of the thioamide before giving iodine. This waiting period prevents further synthesis of new thyroid hormone before adequate blockade of the thyroid hormone synthesis pathway is achieved. 6, 7 Iodine can be given via Lugol's solution or SSKI. Dosing is 8 drops of Lugol's every 6 hours or 5 drops of SSKI every 6 hours. 2, 5 The typical supportive care measures of antipyretics, volume resuscitation, and blood pressure support also apply. Avoid administration of salicylates, since this may increase the level of free thyroid hormones • Providers should keep in mind the pathophysiology of this condition when considering other medication use. Avoidance of anything that may increase sympathetic tone is important; i.e. albuterol or pseudoephedrine. 6