Thyroid storm (TS), also known as hyperthyroid crisis, is a life-threatening endocrine emergency. Hyperthyroidism is multi-organ failure caused by severe thyrotoxicosis, which occurs more often in untreated or inadequate grateemia, but is also rare in other thyrotoxic diseases.
At the 20th National Conference on Endocrinology of the Chinese Medical Association (CSE2023), Professor Lv Zhaohui from the First Medical Center of the General Hospital of the Chinese People's Liberation Army gave a wonderful speech on the assessment and treatment of hyperthyroid crisis.
Epidemiology of hyperthyroid crisis.
In a US study of 121384 patients diagnosed with thyrotoxicosis between 2004 and 2013, 19,723 (16.)2%) were diagnosed with hyperthyroid crisis, with an overall annual incidence of (0.).57-0.76) per 100,000 people, while the annual incidence rate in hospitalized patients is (4.)8-5.6) 100,000 people. The annual incidence of hyperthyroid crisis in hospitalized patients in Japan is 02 100,000 people, accounting for 022%, accounting for 54%, with a case fatality rate of more than 10%. There is also literature suggesting that the case fatality rate of hyperthyroid crisis is approximately 20 percent [1].
The current situation of diagnosis and treatment of hyperthyroid crisis in China is low morbidity but high mortality. From 2007 to 2017, 23 patients with hyperthyroid crisis were diagnosed in the Affiliated Hospital of Zunyi Medical College, and the average incidence of hyperthyroid crisis accounted for 0 of the patients with hyperthyroidism in 10 years17, accounting for 0 of the total inpatients in the hospital04, the male-to-female ratio is about 1:3. Among them, the rate of missed diagnosis and misdiagnosis in emergency department was 4348% with a mortality rate of 391%。[2] Therefore, for hyperthyroid crisis, early recognition and correct treatment are key!
Early recognition of hyperthyroid crisis.
The biggest problem in clinical hyperthyroid crisis is how to identify it early. There is no gold standard for the diagnosis of hyperthyroid crisis, and the diagnosis cannot be confirmed by a single test, and there is a lack of specific diagnostic indicators. The diagnosis of hyperthyroid crisis in China, Europe and the United States mainly depends on the clinical manifestations and the comprehensive judgment of Burch &Wartofsky (BWPS), while in Japan it is judged by the clinical manifestations combined with the JTA classification. Let's take a look at what the two methods are.
To determine whether a patient has an hyperthyroid crisis, the patient needs to be examined for thyrotoxicosis, which occurs and the following symptoms are present
Symptoms of high metabolic rate and high adrenergic response [3].
1) High fever, the increase in body temperature is generally around 40, and it is difficult to reduce fever with conventional antipyretic measures.
2) palpitations, shortness of breath, significantly faster heart rate, generally more than 160 beats, large pulse pressure difference, often atrial fibrillation, tachycardia, anti-arrhythmic drugs are difficult to work.
3) Sweating all over the body, flushing, hot flashes.
Digestive symptoms.
Loss of appetite, nausea, vomiting, diarrhea, and in severe cases, jaundice.
Neurological symptoms.
Extreme fatigue, irritability, delirium and even coma.
Atypical presentation.
Apathy, sluggishness, lethargy, and even stupor.
Hyperthyroid crisis is characterized by multi-organ failure, which is the leading cause of death in patients with hyperthyroid crisis. Hyperthyroid crisis is largely clinically diagnostic, and although serum free T3 (FT3) or free T4 (FT4) levels are elevated in hyperthyroid crisis, there is no clear cut-off point for serum FT4 or FT3 to distinguish common thyrotoxicosis from hyperthyroid crisis. However, thyroid function tests are not useless, and thyroid function tests are helpful and may indicate the severity of organ damage.
In addition to diagnosing hyperthyroid crisis based on clinical symptoms, the 2022 new edition of the Chinese Guidelines for Hyperthyroidism recommends a BWPS scoring system, which should be based on clinical judgment for patients with a score between 25 and 44Patients with a score above 45 are diagnosed with hyperthyroid crisis. In the diagnostic process, the doctor's experience is very important, and patients with a score between 25 and 44 need to determine the need for ** based on the doctor's experience, which determines the patient's prognosis.
The prerequisites for the diagnosis of hyperthyroid crisis by the Japanese Thyroid Association (JTA) are the presence of thyrotoxicosis, elevated FT3 and FT4 levels, and the predominant clinical symptom is neurological.
Therefore, the diagnosis of hyperthyroid crisis in JTA requires thyrotoxicosis and at least one neurologic manifestation with fever, tachycardia, congestive heart failure, gastrointestinal manifestations, and other symptoms. If the patient does not have neurological manifestations, 3 of the other symptoms such as fever, tachycardia, congestive heart failure, and gastrointestinal manifestations are required.
The JTA also stresses that it is important to rule out other conditions when diagnosing a hyperthyroid crisis. Diagnosis should be excluded if other underlying medical conditions cause fever (eg, pneumonia and malignant hyperthermia), impaired consciousness (eg, psychiatric disorders, cerebrovascular disorders), heart failure (eg, acute myocardial infarction), and liver disease (eg, viral hepatitis, acute liver failure).
Professor Lu Zhaohui suggested that two diagnostic evaluation systems should be used together to diagnose the patient's condition.
Principle of hyperthyroidism**.
After the correct diagnosis of hyperthyroid crisis, how to ** becomes the key. The first is to control thyrotoxicosis (decreased thyroid hormone secretion and production), and the second is to improve the patient's systemic symptoms and signs, including hyperthermia, dehydration, shock, and disseminated intravascular coagulation. In addition, it targets multi-organ failure, such as cardiovascular, neurological, and hepatogastrointestinal, and removes the trigger for hyperthyroid crisis [5,6]. So how to choose related drugs?
Drugs**. In 2007, CSE recommended the preferential use of propylthiouracil (PTU), with an initial dose of 600 mg orally or via gastric tube, followed by 200 mg every 8 hoursor methimazole (MMI) with an initial dose of 60 mg orally, followed by 20 mg every 8 hoursIodine** can also be used, with iodine after 1 hour of ATD, 5 drops of compound iodine solution every 6 hours, or sodium iodide 10g dissolved in 500ml of liquid intravenous infusion, 1 3g can be used in the first 24 hours. In addition to the above three drugs, it is also necessary to use cooling, heart failure drugs, hormones, receptor blockers, etc. according to the patient's symptoms.
In the use of the above ** effective, the condition can be significantly improved within 1 2 days, recovery within 1 week, after which the dose of iodine and glucocorticoids is gradually reduced until the drug is stopped. If the above routine** results are not effective, peritoneal dialysis, hemodialysis, or plasma exchange can be used to rapidly reduce plasma thyroid hormone concentrations.
Precautions. When ATDS is contraindicated due to severe ***, cholestyramine and lithium carbonate can effectively reduce thyroid hormone levels.
It is also important to teach patients how to prevent hyperthyroid crisis in their daily routines. The most common cause of a crisis is poor medication adherence or abrupt interruption of ATDS, so it is necessary to inform patients in clinical work that they must take their medication regularly and inform them of the risks, such as radioactive iodine** or thyroidectomy.
Surgical departments should monitor the patient's general condition and thyroid hormone levels before and after radioactive iodine**, thyroidectomy, or non-hyperthyroidism surgery to prevent hyperthyroid crisis.
References: 1].chiha, m. et al. j intensive care med. 2015; 30 (3):131-140.[2].Liu Anping, et al., Journal of Zunyi Medical College. 2017:40（⑤5）：5570559[3].akamizu t et al. thyroid. 2012; 22(7): 661-79.[4].Emergency Medicine Branch of Chinese Medical Association, Professional Committee of Chinese Medical Association, Visiting Physician Branch of Chinese Medical Doctor Association;Beijing Medical Association, Expert Consensus on Emergency Diagnosis and Treatment of Thyroid StormChinese Journal of Emergency Medicine, 2021, 30(06): 563-670[5].satoh, tet al. endocr 1. 2016; 63 (12): 1025-1064 [6].akamlzu t, et al. thyrold. 2012 jul;22(7):661-79.