SIMULATION Thyroid Storm in the Emergency Department

: Introduction: Thyroid storm represents the extreme manifestation of thyrotoxicosis. 1 It ranks as one of the most critical illnesses in the spectrum of endocrine emergencies. 1 Recognition and appropriate management of life-threatening thyrotoxicosis is vital to prevent the high morbidity and mortality that may accompany this disorder. The incidence of thyroid storm has been noted to be less than 10% of patients hospitalized for thyrotoxicosis; however, the mortality rate due to thyroid storm ranges from 20%-30%. 1 This simulation case allows the trainee to practice important critical decision-making skills in the evaluation and management of a patient presenting with thyroid storm. Objectives: By the end of this simulation-based session, the learner will be able to: 1) Recognize the signs and symptoms of thyroid storm and appropriately diagnose a patient with thyroid storm. 2) Choose appropriate medications for the treatment of thyroid storm. 3) Determine the appropriate disposition for a patient presenting in thyroid storm. 4) Discuss the rationale behind each drug used to treat thyroid storm. 5) List at least three precipitants of thyroid storm. Method: This case can be run as a low, medium, or high-fidelity simulation. a chief of and confusion. Upon further of at participants will discover that has a history of hyperthyroidism. On exam, she is tachycardic, hypertensive, febrile, and confused. Electrocardiogram (ECG) will show sinus tachycardia. Chest X-ray will show right middle lobe pneumonia. Participants should recognize that the patient is in thyroid storm, likely precipitated by pneumonia, and initiate appropriate treatments and admit the patient to the medical intensive care unit (ICU). If the participant does not initiate appropriate therapies for thyroid storm, the patient will deteriorate into a hemodynamically unstable rhythm, arrest, and will expire if no appropriate thyroid storm treatment is initiated.

Background and brief information: The scenario takes place in an emergency department at a community hospital.The patient is brought in by family for evaluation after fever, cough and confusion for two days.

Initial presentation:
The patient presents to the emergency department by private auto complaining of fever, cough, and confusion for two days.She is agitated and the family provides most of the history.
How the scenario unfolds: The case begins with the patient presenting to the emergency department with two days of fever, cough, and confusion.The learners should immediately assess the patient's airway, breathing, and circulation, while requesting that the patient be placed on a cardiac monitor and pulse oximeter, obtaining an initial set of vital signs, and requesting large-bore IV access.Initial vital signs will be significant for tachycardia, hypertension, mild hypoxia, and an elevated temperature.Learners should place the patient on supplemental oxygen, start IV fluids, and request that laboratory studies be obtained.Participants should also perform a targeted history and physical examination.Since the patient will be altered on exam, the companion (husband or sister depending on confederate available) who accompanies the patient provides the majority of the history.The patient's physical examination will be significant for agitation, coarse right-sided lung sounds, and stigmata of hyperthyroidism (exophthalmos, thyromegaly, etc.).A chest X-ray and electrocardiogram should also be obtained.The chest X-ray will be significant for a right middle lobe consolidation.
The learners should recognize that the patient is in thyroid storm, which was likely precipitated by the pneumonia, and should start the appropriate treatment for both.If the learners start a beta-blocker medication, the patient's tachycardia and hypertension will improve.If the beta-blocker is not started, the patient will become increasingly tachycardic and hypertensive.Learners should also initiate treatment with thionamides, preferably propylthiouracil (since it decreases the synthesis of new hormone and inhibits peripheral conversion of T4 to T3); however, methimazole may also be used.Iodine therapy such as Lugol's solution or potassium iodide should also be started; however, it is important for the participant to verbalize that iodine therapy should be started at least one hour after thionamides are given.If iodine is given before thionamides, then the patient will develop worsening tachycardia and hypertension.Glucocorticoids should also be given.Broadspectrum antibiotics should also be initiated for the treatment of the pneumonia and sepsis.If the participant does not initiate appropriate therapies for thyroid storm and sepsis, the patient will deteriorate into a hemodynamically unstable rhythm and will have to be intubated.Appropriate disposition for this patient is admission to the ICU.
• Breathing: Slightly coarse sounds to right chest, left chest is clear to auscultation.
• Circulation: Pulses present in all extremities, tachycardic and regular.

History:
• History of present illness: This is a 67-year-old female presenting with fever, cough, and confusion.Per family at bedside, patient has had symptoms of rhinorrhea and cough for the past several days.Cough has become more productive-sounding and patient developed a fever today.Today, they noted that patient became confused and agitated.At baseline, she is alert and oriented and able to care for herself and perform all activities of daily living (ADLs).• Past medical history: Hypertension, diabetes, hyperthyroid, arthritis.

Thyroid Storm
Debriefing Points: Note: It is recommended that during the debriefing, the common precipitants of thyroid storm are emphasized, in order to achieve learning objective 5.It is also recommended that the pathophysiology of thyroid storm and how this relates to the various medications for treatment is emphasized, in order to achieve learning objective 4. The following questions may be considered to prompt discussion: • What are common precipitants of thyroid storm?
• What is the pathophysiology of thyroid storm?
• What are the pharmacologic therapies for thyroid storm?

Pearls:
Brief background: • In the spectrum of endocrine emergencies, thyroid storm ranks as one of the most critical.• Incidence of thyroid storm has been noted to be <10% of patients hospitalized with thyrotoxicosis; however, mortality rate due to thyroid storm ranges from 20%-30%.• Hyperthyroidism refers to disorders that result from overproduction of hormone.
• Thyrotoxicosis refers to any cause of excessive thyroid hormone concentration.
• Thyroid storm represents an extreme manifestation of thyrotoxicosis.

Normal thyroid physiology:
• Anterior pituitary regulates synthesis/release of thyroid hormone through thyroid stimulating hormone (TSH).• After being released from thyroid gland, thyroid hormones are reversibly bound to circulating plasma proteins, mainly thyronine-binding globulin (TBG).• Free, unbound portions of hormone are biologically active.
• Thyroxine (T4) is the predominant circulating hormone.It is peripherally deiodinated to triiodothyronine (T3), which is more biologically active than T4.• Most actions of thyroid hormone are at the cellular level.

Etiology:
• The most common underlying cause of thyrotoxicosis in cases of thyroid storm is Grave's disease.Differential diagnosis: (note: this is not an exhaustive differential) • Goal is to stop synthesis of new hormone within the thyroid gland, halt the release of stored hormone in the thyroid gland, decrease conversion of T4 to T3, control the adrenergic symptoms of thyrotoxicosis, and control systemic decompensation with supportive therapy.• It is very important that a thionamide is initiated before iodine therapy, to prevent the stimulation of new thyroid hormone synthesis that can occur if iodine is given initially.o Use beta blockers with caution in those with decompensated heart failure or other contraindications (eg, asthma).

• Glucocorticoids:
o Recommended in life-threatening thyroid storm.
o Has an inhibitory effect on peripheral conversion of T4 to T3, and also treats possible relative adrenal insufficiency.

Assessment Timeline
This timeline is to help observers assess their learners.It allows observer to make notes on when learners performed various tasks, which can help guide debriefing discussion.

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Diagnosis of thyroid storm is based on the presence of severe and life-threatening symptoms (hyperpyrexia, cardiovascular dysfunction, altered mentation) in a patient with biochemical evidence of hyperthyroidism (low TSH/high T4 or T3). 2 • There are no universally accepted criteria or validated clinical tools for diagnosing thyroid storm.• An objective scoring system, developed in 1993 by Burch and Wartofsky, uses precise clinical criteria for the identification of thyroid storm. 1 However, distinction between severe thyrotoxicosis and thyroid storm is a matter of clinical judgment.It is recommended to treat patients in an active preemptory fashion when possible, instead DEBRIEFING AND EVALUATION PEARLS eturn: Calibri Size 10 McCoy C E, et al.Thyroid Storm in the Emergency Department.JETem 2019.4(3):S68-93.https://doi.org/10.21980/J8234R87of excessively contemplating whether the patient really meets criteria for thyroid storm.1 • Thionamides: o Stops synthesis of thyroid hormone by interfering with the thyroperoxidasecatalyzed coupling process within 1-2 hours of administration.o Propylthiouracil or methimazole can be used.o Propylthiouracil is preferable since it decreases the synthesis of new hormone and inhibits peripheral conversion of T4 to T3. • Iodine: o Blocks the release of prestored hormone (Wolff-Chaikoff effect).o Iodine therapy should be delayed for at least one hour after thionamide therapy.o Oral formulations include Lugol's solution and saturated solution of potassium iodide (SSKI).• Beta blockade: o Propranolol most commonly used beta blocker.In addition to beta blockade, it also reduces serum T3 levels in high doses.o Can also consider esmolol.DEBRIEFING AND EVALUATION PEARLS eturn: Calibri Size 10 McCoy C E, et al.Thyroid Storm in the Emergency Department.JETem 2019.4(3):S68-93.https://doi.org/10.21980/J8234R88 2. Establish two large bore IV lines.3. Place the patient on oxygen (at least nasal cannula (NC) 4-6 L/min).A 67-year-old female presents to the emergency department with a chief complaint of fever, cough, and confusion.
4. Place patient on monitors (cardiac monitor and pulse oximetry monitor).5.Give broad spectrum antibiotics.6.Give medication to decrease hormone synthesis (preferably propylthiouracil but methimazole is acceptable).7.Give medication to prevent hormone release (saturated solution of potassium iodine[SSKI], Lugol solution, or lithium carbonate), and learners should verbalize that it should be given at least one hour after thionamides.8.Prevent peripheral hormone effects (beta blockade, steroids, guanethidine, or reserpine).9.Admit patient to MICU service.INSTRUCTOR MATERIALSeturn: Calibri Size 10 McCoy C E, et al.Thyroid Storm in the Emergency Department.JETem 2019.4(3):S68-93.https://doi.org/10.21980/J8234R73 Case title: Thyroid Storm in the Emergency Department Chief Complaint:

Family history: Non-contributory. Secondary Survey/Physical Examination: • General appearance: Appears
stated age, thin-appearing, agitated and confused.