Table of Contents
Introduction:
A thyroid storm (commonly known as a thyrotoxic crisis) is an emergency medical condition occurring in patients with hyperthyroidism. This acute condition is life-threatening and complex, involving multiple systems of the body. Despite modern advancements, the mortality rate linked to thyroid storms is around eight to 25 percent. Thus, it is essential to prevent the condition. Once the person shows symptoms of thyroid storm, it is vital to recognize them as early as possible and initiate aggressive treatment to prevent death.
What Happens in a Thyroid Storm?
The thyroid gland in the neck releases the hormones T3 (triiodothyronine) and T4 (thyroxine). These thyroid hormones help to regulate the heart rate, metabolism, and body temperature. A thyroid crisis or thyroid storm occurs due to the release of these thyroid hormones in large amounts in a short duration. As a result, the body's metabolism increases to dangerously high levels, increasing oxygen demand. In order to meet the oxygen requirement, the heart begins to pump blood rapidly. This increases the heart rate (tachycardia), ultimately resulting in cardiac failure. A thyroid storm is a rare medical emergency (about five to seven people per million are affected). It is seen in hyperthyroidism patients or in individuals with thyroid disorders such as goiter, toxic adenoma of the thyroid, and Grave's disease (an autoimmune disease that can cause hyperthyroidism).
What Factors Precipitate Thyroid Storm?
The exact cause of the thyroid storm is unknown. However, the following can trigger a thyroid storm emergency:
- Long-term undertreated or untreated hyperthyroidism.
- Graves disease (an immune system disorder that can lead to an overactive thyroid).
- Toxic multinodular goiter (the thyroid gland is enlarged and has multiple nodules that produce too much thyroid hormone).
- Toxic thyroid adenoma (an active benign tumor of the thyroid gland).
- If a person suddenly stops taking their antithyroid medicines.
- Thyroid surgery (especially if the patient is poorly prepared before the surgery).
- Non-thyroid surgery in a patient with hyperthyroidism.
- Infections.
- The use of iodinated contrast (for certain imaging scans) can trigger a thyroid crisis due to a large amount of iodine in the body.
- Radioiodine therapy.
- Trauma (especially traumatic brain injury).
- Acute illnesses such as stroke, diabetic ketoacidosis, Covid-19, acute myocardial infarction (heart attack), and heart failure.
- Drug reaction leading to acute illnesses.
- During labor (delivery) and hyperemesis gravidarum (excessive vomiting) in pregnancy.
How to Prevent Thyroid Storms?
It is difficult to predict and prevent all cases of thyroid storms, especially if the patient does not have hyperthyroidism. However, if the patient has an overactive thyroid or hyperthyroidism, the following can help to reduce the risk of thyroid storm:
- Taking thyroid medicines as prescribed by the doctor.
- Avoid discontinuing thyroid medications suddenly, without the doctor's recommendation.
- Regularly visiting a doctor or healthcare provider to follow up on the treatment response.
- Managing stress.
- Use of antithyroid medications (as prescribed by the doctor) before surgeries.
- Maintaining a healthy lifestyle (with well-balanced food intake and healthy habits).
- Routine health check-ups and screening for thyroid-related issues (including doctor-recommended blood work).
- In pregnant women, screening for thyroid hormone levels before, during, and after delivery.
- The patients must be educated about the consequence of suddenly stopping (discontinuing) antithyroid medications.
- Identifying the triggers and common precipitants and avoiding them.
- Healthcare providers must ensure that the patient's thyroid levels are normal before elective surgeries and other procedures.
- Seeking medical help immediately if the symptoms (such as fever or rapid heart rate) of hyperthyroidism become severe or if a thyroid storm is suspected.
How to Prevent Thyroid Storm in Pregnancy?
In a pregnant woman, hyperthyroidism can occur due to excess production of thyroid hormones (hyperfunction of the thyroid gland) or exposure to thyroid hormones due to various reasons. The most common cause of hyperthyroidism during pregnancy is Graves' disease (an immune system disorder). This can cause symptoms such as nervousness, tremors, excessive sweating, insomnia, heat intolerance, increased heart rate, increased blood pressure, and goiter. Thyroid storm affects one percent of pregnant women (with hyperthyroidism). These are seen more commonly during delivery and labor and in women with a condition known as hyperemesis gravidarum (excessive vomiting). The signs and symptoms of hyperthyroidism are severe, acute, and exacerbated in thyroid storms, requiring emergency medical attention. Thyroid storms can lead to complications such as preterm delivery (with neonates with low birth weight), severe preeclampsia, heart failure, and miscarriage.
A thyroid profile screening at prenatal and antenatal care is vital to prevent or reduce the chance of thyroid storms in pregnant women. The screening for hyperthyroidism must be done along with a thorough personal history and assessment of symptoms. If a thyroid storm is suspected, immediate treatment involving a multidisciplinary team is essential for the fetus and mother's well-being. The baby must be monitored continuously (in-utero), and management must be based on the mother's response to the treatment.
How to Prevent Thyroid Storms During Surgeries?
Thyrotoxic crises or thyroid storms are often associated with surgical procedures and anesthesia. These can occur during and after the surgical procedure (up to six to 18 hours after the surgery). In order to reduce the chance of thyroid storm occurring during anesthesia or surgery, careful patient assessment, preparation and premedication, and pretreatment with antithyroid medications are essential. If the hyperthyroid patients are not adequately prepared (ensuring that their thyroid hormone levels are normal before surgery), there is a higher chance of thyroid storm. The healthcare provider must remain alert when surgeries are scheduled for patients with hyperthyroidism.
Once a thyroid storm develops, it has to be managed immediately by treating the underlying cause or illness and taking measures to reduce the production of thyroid hormones. In addition, general supportive measures (such as fluid replacement or temperature control) and measures and medications to decrease the metabolic effects of the raised thyroid hormones are vital to prevent complications and death.
Conclusion:
Immediate medical attention and treatment are essential for thyroid storm emergencies. Treatment should be continued till the thyroid levels normalize. Definitive treatment includes antithyroid medications, surgical management, or 131-I therapy (iodine therapy). Sometimes urgent removal of the thyroid gland (emergency thyroidectomy) is performed, with careful patient preparation with antithyroid medicines, beta-blockers, and iodide administration. Prevention involves identifying the triggers and common precipitants and avoiding them. The patients must be educated about the consequence of suddenly stopping (discontinuing) antithyroid medications. It is also important that healthcare providers ensure that the patient's thyroid levels are normal before elective surgeries and other procedures (including labor and delivery).
