eMedicine Specialties > Emergency Medicine > Endocrine & Metabolic

Hyperthyroidism, Thyroid Storm, and Graves Disease: Follow-up

Author: Erik D Schraga, MD, Consulting Staff, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates; Consulting Staff, Permanente Medical Group, Kaiser Permanente, Santa Clara Medical Center
Contributor Information and Disclosures

Updated: Jun 3, 2009

Follow-up

Further Inpatient Care

  • Admit patients with thyroid storm to the intensive care unit.
  • Severely thyrotoxic patients should be admitted to a monitored setting.
  • Confirm the diagnosis with laboratory analysis.
  • Clinical improvement should be evident within hours of initiating therapy.
  • Monitor therapy by laboratory values and clinical assessment. Titrate medications to optimize antithyroid and antiadrenergic effects.
  • Therapy may be required for 4-8 weeks.
  • Aggressively treat infection and any other underlying precipitant.

Further Outpatient Care

  • Patients with mild-to-moderate hyperthyroidism or Graves disease should follow up with their primary care physician or endocrinologist after a period of ED monitoring.

Transfer

  • Initiate antithyroid therapy for patients with thyrotoxicosis.
  • Ensure hemodynamic stability prior to transfer.
  • Consider transfer if intensivist or endocrinologist is not available to assist inpatient management.

Complications

  • Surgical complications
    • Hypoparathyroidism
    • Damage to recurrent laryngeal nerve
    • Hypothyroidism with subtotal thyroidectomy
  • Development of hypothyroidism following radioiodine treatment
  • Visual loss or diplopia due to severe ophthalmopathy
  • Localized pretibial myxedema
  • High-output cardiac failure
  • Muscle wasting and proximal muscle weakness

Prognosis

  • Thyroid storm is usually fatal if untreated.
    • Overall rate of mortality due to thyroid storm is approximately 10-20% but has been reported as high as 75%; the precipitating factor or underlying illness is often the cause of death.
    • With early diagnosis and adequate treatment, the prognosis is good.

Patient Education

  • Stress the importance of medication compliance.
  • Provide return precautions including symptoms suggestive of secondary hypothyroidism and undertreated hyperthyroidism.
  • For excellent patient education resources, visit eMedicine's Endocrine System Center. Also, see eMedicine's patient education articles Thyroid Problems and Thyroid Storm.

Miscellaneous

Medicolegal Pitfalls

  • Because of the variable presentation of hyperthyroidism, even severe forms may be missed initially, particularly when patients present obtunded or comatose.
  • Apathetic thyrotoxicosis often is missed in the elderly (ie, aged 70-80 y). Symptoms consistent with apathetic thyrotoxicosis include prolonged duration of symptoms, increased weight loss, cardiovascular abnormalities (common), and ocular findings (less common).
  • Consider the possibility of thyrotoxicosis whenever a patient with acute behavioral changes is referred for psychiatric evaluation.

Special Concerns

  • Secondary hypothyroidism is a risk after thyroid surgery, radioablation, or thyroiditis.
  • Symptoms of thyrotoxicosis may be overlooked in pregnancy, as they may be indistinguishable from normal physiologic changes.
  • Hyperthyroidism during pregnancy warrants especially close attention and almost always should be treated with antithyroid medications.
  • Although surgery has been performed successfully during pregnancy, no data show that it has any significant advantage over antithyroid drugs as treatment. Since the necessary pretreatment with radioiodine is contraindicated, surgery should only be used if medical management is unsuccessful.
  • Iodide should not be used in pregnancy unless the benefits outweigh the risks, as it can lead to goiter development in the fetus.
  • During pregnancy, PTU should be used preferentially over methimazole. Each of these agents crosses the placental barrier and inhibits fetal thyroid function, but PTU crosses less readily.
 
Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author, Craig A Manifold, DO, to the development and writing of this article.



More on Hyperthyroidism, Thyroid Storm, and Graves Disease

Overview: Hyperthyroidism, Thyroid Storm, and Graves Disease
Differential Diagnoses & Workup: Hyperthyroidism, Thyroid Storm, and Graves Disease
Treatment & Medication: Hyperthyroidism, Thyroid Storm, and Graves Disease
Follow-up: Hyperthyroidism, Thyroid Storm, and Graves Disease
References
[ CLOSE WINDOW ]

References

  1. FDA MedWatch Safety Alerts for Human Medical Products. Propylthiouracil (PTU). US Food and Drug Administration. Available at http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm164162.htm. Accessed June 3, 2009.

  2. Basaria S, Cooper DS. Amiodarone and the thyroid. Am J Med. Jul 2005;118(7):706-14. [Medline].

  3. Braverman LE, Utiger RD. Werner and Ingbar's The Thyroid: A Fundamental and Clinical Text. 7th ed. 1996.

  4. Burch HB, Wartofsky L. Life-threatening thyrotoxicosis. Thyroid storm. Endocrinol Metab Clin North Am. Jun 1993;22(2):263-77. [Medline].

  5. Canaris GJ, Manowitz NR, Mayor G, Ridgway EC. The Colorado thyroid disease prevalence study. Arch Intern Med. Feb 28 2000;160(4):526-34. [Medline].

  6. Cappola AR, Fried LP, Arnold AM, et al. Thyroid status, cardiovascular risk, and mortality in older adults. JAMA. Mar 1 2006;295(9):1033-41. [Medline].

  7. Carlson HE. Gynecomastia. N Engl J Med. Oct 2 1980;303(14):795-9. [Medline].

  8. Cooper DS. Antithyroid drugs. N Engl J Med. Mar 2005;352(9):905-17. [Medline].

  9. Fisher JN. Management of thyrotoxicosis. South Med J. May 2002;95(5):493-505. [Medline].

  10. Gharib H. Changing concepts in the diagnosis and management of thyroid nodules. Endocrinol Metab Clin North Am. Dec 1997;26(4):777-800. [Medline].

  11. Glauser J, Strange GR. Hypothyroidism and hyperthyroidism in the elderly. Emerg Med Rep. 2002;1(2):1-12.

  12. Hollowell JG, Staehling NW, Flanders WD, et al. Serum TSH, T(4), and thyroid antibodies in the United States population (1988 to 1994): National Health and Nutrition Examination Survey (NHANES III). J Clin Endocrinol Metab. Feb 2002;87(2):489-99. [Medline].

  13. Kudrjavcev T. Neurologic complications of thyroid dysfunction. Adv Neurol. 1978;19:619-36. [Medline].

  14. McKeown NJ, Tews MC, Gossain VV, Shah SM. Hyperthyroidism. Emerg Med Clin North Am. Aug 2005;23(3):669-85, viii. [Medline].

  15. Pimentel L, Hansen KN. Thyroid disease in the emergency department: a clinical and laboratory review. J Emerg Med. Feb 2005;28(2):201-9. [Medline].

  16. Ragland E, Urbanic RC. Thyroid emergencies. In: Harwood-Nuss Al, Linden CH, eds. The Clinical Practice of Emergency Medicine. 2nd ed. Lippincott Williams & Wilkins; 1996:736-41.

  17. Ragland G. Thyroid storm. In: Emergency Medicine: A Comprehensive Study Guide. 4th ed. New York, NY: McGraw-Hill; 1996:736-9.

  18. Ringel MD. Management of hypothyroidism and hyperthyroidism in the intensive care unit. Crit Care Clin. Jan 2001;17(1):59-74. [Medline].

  19. Rozien MF. Anesthetic implications of concurrent diseases. In: Anesthesia. Churchill Livingstone; 1994:926-8.

  20. Rozien MF, Fleisher LA. Essence of Anesthesia Practice. WB Saunders Co; 1997:177.

  21. Scott SK. Thyroid disorders. In: Markovchick VJ, Pons PT, Wolfe RE, eds. Emergency Medicine Secrets. Hanley and Belfus; 1993:178-82.

  22. Sniezek JC, Francis TB. Inflammatory thyroid disorders. Otolaryngol Clin North Am. Feb 2003;36(1):55-71. [Medline].

  23. Streetman DD, Khanderia U. Diagnosis and treatment of Graves disease. Ann Pharmacother. Jul-Aug 2003;37(7-8):1100-9. [Medline].

  24. Tietgens ST, Leinung MC. Thyroid storm. Med Clin North Am. Jan 1995;79(1):169-84. [Medline].

  25. Waldstein SS, Slodki SJ, Kaganiec GL. A clinical study of thyroid storm. Ann Intern Med. 1960;52:626-42.

  26. Warofsky L, Ingbar SH. Diseases of the thyroid. In: Wilson JD, Brunwald E, et al, eds. Harrison's Principles of Internal Medicine. McGraw-Hill; 1991:1692-1712.

  27. Weetman AP. Graves' disease. N Engl J Med. Oct 26 2000;343(17):1236-48. [Medline].

  28. Wogan JM. Endocrine disorders. In: Rosen P, Barkin RM, et al, eds. Emergency Medicine: Concepts and Clinical Practice. Mosby-Year Book; 1992:2242-59.

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Erik D Schraga, MD, Consulting Staff, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates; Consulting Staff, Permanente Medical Group, Kaiser Permanente, Santa Clara Medical Center
Disclosure: Nothing to disclose.

Medical Editor

Robin R Hemphill, MD, MPH, Associate Professor, Director, Disaster Preparedness, Department of Emergency Medicine, Vanderbilt University Medical Center
Robin R Hemphill, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Howard A Bessen, MD, Professor of Medicine, Department of Emergency Medicine, UCLA School of Medicine; Program Director, Harbor-UCLA Medical Center
Howard A Bessen, MD is a member of the following medical societies: American College of Emergency Physicians
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.