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 Vitals: 101.9 167 153/86 26 Agitation Scleral icterus Bilateral crackles with expiratory wheezing Palpitations Mild diaphoresis and nausea without emesis No obstruction of airway 2 /2 goiter 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 Temp: 99-99.9 100-100.9 ≥ 104.0 90-109 110-119 120-129 ≥140 5 points 10 points 15 points 25 points 0 points 10 points Precipitating Event Absent Present 0 points 10 points Absent 0 points Mild (pedal edema) 5 points Moderate (bb rales) 10 points Severe(pulm edema) 15 points CNS A. Fib Absent Present CHF 5 points 10 points 30 points Tachycardia Absent Mild Moderate Severe 0 points 10 points 20 points 30 points GI-Hepatic Absent Moderate Severe 0 points 10 points 20 points 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? 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 “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.