Thyroid Storm

[saintsfan180]

Question for board purposes:

InTrainingPrep said that the first medication to give in thyroid storm is Propranolol to prevent end organ damage, then give PTU, then 1 hour later give Iodine.

RoshReview is saying that PTU is the first med to give, then in the answers it says that Propranolol is first line. I'm a little confused. Looks like Tintinalli lists PTU as the first treatment as well.

I'm sure in reality you'd be giving these 2 basically together, but for the question's sake, what's the right answer? Attendings? Residents more experienced than me?

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[Bostonredsox]

Question for board purposes:

InTrainingPrep said that the first medication to give in thyroid storm is Propranolol to prevent end organ damage, then give PTU, then 1 hour later give Iodine.

RoshReview is saying that PTU is the first med to give, then in the answers it says that Propranolol is first line. I'm a little confused. Looks like Tintinalli lists PTU as the first treatment as well.

I'm sure in reality you'd be giving these 2 basically together, but for the question's sake, what's the right answer? Attendings? Residents more experienced than me?

IM PGY-2 here, We had a thyroid storm a few weeks back, wrote it up, nice case. Presented mid 40s AA male with new onset AF with RVR. HR persistantly in 170s. ED attending, who is an old FP doc not exactly current evidenced based medicine ED trained, was loading with dilt x2 boluses plus a drip for what he presumed was just difficult to control AF RVR, called me for MICU admission for inability to control HR. I walked in, his eyes were literally 7 inches outside of his skull, most impressive physical exam finding I have seen to date, asked for stat TSH and t4/t3. I bolused esmolol and started a drip along with methimazole PO, we were on backorder for PTU. Esmolol far more rapid acting for the RVR than propranalol, and titratable. He seized (probable ETOH withdrawl) shortly after, so RSI'd him and then CTd his head and chest, chest with contrast given high dimer, but in reality, I asked for it with iodinated contrast knowing it would benefit his thyroid storm which was my suspicion all along. TSH came back 0.0 as I came back from CT. after CT, added steroids and SSKI drops via OGT. Took him up to MICU. esmolol controlled the RVR nicely he actually converted overnight to SR. Stayed in ICU 4 days, a bit longer as he was tough to extubate given high amount of sedation needed for his ETOH withdrawl. Walked home on PTU, which they recommend converting methimazole too at discharge if you started with it.

In short, in my mind. The hemodynamics come first. If your guy is a true thyroid storm and as unstable as mine was, beta block him first before he arrests. shove the PTU or methimazole in right after. but the PTU is not going to stablize him. Needs beta blockade.

 

[Rendar5]

I agree that esmolol is great given it's titratability, but something to keep in mind (and not saying you're wrong with your beta-blocker choice at all in this situation) is that esmolol is a selective beta-1 blocker. propranol is the prototypical for thyroid storm in general because it hits beta 1,2, and 3 receptors, Either way typical teaching in thyroid storm is that Beta-blockade is step 1 as far as boards go.

 

[PlutoBoy]

I agree that esmolol is great given it's titratability, but something to keep in mind (and not saying you're wrong with your beta-blocker choice at all in this situation) is that esmolol is a selective beta-1 blocker. propranol is the prototypical for thyroid storm in general because it hits beta 1,2, and 3 receptors, Either way typical teaching in thyroid storm is that Beta-blockade is step 1 as far as boards go.

Propranolol also inhibits conversion of T4 to T3. This added benefit is what makes it first line.

 

[Bostonredsox]

Propranolol also inhibits conversion of T4 to T3. This added benefit is what makes it first line.

Both of you are correct. So i guess in regards to the OPs original question, for boards, probably the inderal. However, in RL, most of these patients are quite unstable and I would hit them with rapid acting esmolol first. If theyre not tachy'n away at 170s like mine and are a more reasonable 120s with good BP, by all means use inderal, for the obvious reasons the previous 2 posters mentioned.

 

[Rendar5]

Both of you are correct. So i guess in regards to the OPs original question, for boards, probably the inderal. However, in RL, most of these patients are quite unstable and I would hit them with rapid acting esmolol first. If theyre not tachy'n away at 170s like mine and are a more reasonable 120s with good BP, by all means use inderal, for the obvious reasons the previous 2 posters mentioned.

As long as you're treating the disease and not the heart rate. All depends on whether the heart rate's damaging the person or not. I've seen people with HR's in the 150's that were very unstable with heart failure and pulmonary edema developing, but I've also seen people with HR's in the 170's who were stable enough to treat the underlying cause over the course of an hour or so..

 

[Bostonredsox]

As long as you're treating the disease and not the heart rate. All depends on whether the heart rate's damaging the person or not. I've seen people with HR's in the 150's that were very unstable with heart failure and pulmonary edema developing, but I've also seen people with HR's in the 170's who were stable enough to treat the underlying cause over the course of an hour or so..

My guy was crashing lol. Had like 0 cardiac output with his heart rate. He was averaging in the 170s, popping in the 200s quite frequently. When I heard the story over the phone initially I was like cardiovert him? Then I saw him and said ahhhhh, me thinks I know the answer.

 

[Apollyon]

I walked in, his eyes were literally 7 inches outside of his skull, most impressive physical exam finding I have seen to date

7 inches = 17.5cm = "literally"? The entirety of the eye - the globe plus the optic nerve - isn't that long.

 

[Bostonredsox]

yeah it looked like a spongebob squarepants scene where his eyes are hanging down to his mouth by his optic nerves....lol. no I was obviously exaggerating but it was textbook exopthalmos.

 

[WilcoWorld]

Beta block first. Then PTU. Then Iodine. Also give steroids.

As for which beta blocker, I prefer propranolol, because it crosses the blood brain barrier better (say that 3 times fast!), and these patients have CNS symptoms by definition. However, I don't think the choice of beta blocker nearly as critical as giving an adequate dose.