Presentation

• The broad clinical picture is one suggestive of a hypermetabolic state with increased beta-adrenergic activity.
  
• Often more than one disease process may be occurring at once, which makes rapid identification of thyroid storm very difficult. The key is to have a high index of suspicion.

Classic presentation

• Marked tachycardia, often with ventricular rates exceeding 140 bpm.
  
• Fever, temperatures sometimes exceeding 41°C (106°F).
  
• Diaphoresis.
  
• GI symptoms, such as abdominal pain, nausea, vomiting, diarrhea.
  
• CNS dysfunction, agitation, confusion, delirium.

Critical presentation

• High-output cardiac failure and shock.
  
• Atrial fibrillation with rapid ventricular response.
  
• Severely obtunded state, coma, seizure.

Diagnosis and evaluation

• The diagnosis of thyroid storm is made based on clinical findings and laboratory analysis.
  
• Burch and Wartofsky scoring system
  
  
  
  • Given the spectrum of illness, Burch and Wartofsky developed a scoring system to help clinically distinguish uncomplicated thyrotoxicosis from impending thyroid storm and true thyroid storm (Table 60.2).
    
  • A score of 45 or more is highly suggestive of thyroid storm, a score of 25–44 is suggestive of impending thyroid storm, and a score below 25 makes the diagnosis of thyroid storm unlikely.
  
  
• Laboratory testing
  
  
  
  • Laboratory evaluation is primarily directed at assessing the severity of the disease and searching for potential precipitants.
    
  • TSH, T₃, T₄, free T₄
    
  • CBC, basic metabolic profile, lactate, hepatic function panel, lipase.
    
  • Cardiac markers, brain natriuretic peptide (BNP).
    
  • Blood, urine and possibly CNS cultures/analysis.
    
  • A normal TSH virtually excludes the diagnosis of thyroid storm.
  
  
• ECG
  
  
  
  • Evaluate for the presence of atrial fibrillation, other cardiac arrhythmias, or evidence of acute myocardial ischemia.
    
  • The most common cardiac rhythm is sinus tachycardia.
  
  
• Echocardiography
  
  
  
  • Consider bedside echocardiography if suspecting pericardial effusion or significant cardiac dysfunction.
  
  
• Imaging
  
  
  
  • Chest radiography to rule out pneumonia and to evaluate for evidence of congestive heart failure (CHF).
    
  • Consider CT of the head to assess for other potential etiologies of altered mental status.

Table 60.2. Burch and Wartofsky scoring system for thyroid storm

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Thermoregulatory dysfunction (°F)
99–99.9	5
100–100.9	10
101–101.9	15
102–102.9	20
103–103.9	25
104	30
Tachycardia (beats/minute)
90–109	5
110–119	10
120–129	15
130–139	20
140	25
CNS effects
Mild agitation	10
Delirium/psychosis/lethargy	20
Seizure/coma	30
Heart failure
Pedal edema	5
Bibasilar rales	10
Atrial fibrillation	10
Pulmonary edema	15
Gastrointestinal-hepatic dysfunction
Diarrhea/nausea/vomiting/abdominal pain	10
Unexplained jaundice	20
Precipitant history
Positive	10

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