Thyroid Hormone Toxicity Treatment & Management

  • Author: Lisandro Irizarry, MD, MPH, FAAEM; Chief Editor: Asim Tarabar, MD   more...
 
Updated: May 2, 2012
 

Prehospital Care

  • Prehospital management includes gathering evidence of ingestion, administration of charcoal in alert patients with an exposure of more than 5 mg of thyroxine, a full initial assessment, oxygen, and intravenous access as necessary.
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Emergency Department Care

  • If the ingestion is 0.5 mg (500 mcg) or less, discharge the patient home because no gastric decontamination is indicated.[3]
  • Most unintentional exposures could be treated with no decontamination, prudent follow up and observation at home, especially if calculated dose is below 4 mg (4,000 mcg).[4]
    • Phone follow up should be conducted up to 10 days after exposure.
    • Unintentional exposures in excess of 5 mg (5,000 mcg) of thyroxine may benefit from administration of activated charcoal.
    • Intentional massive exposures in excess of 10 mg (10,000 mcg) that present early (within an hour) may benefit from more aggressive decontamination, including gastric lavage, and subsequent administration of activated charcoal.
    • Patients with massive exposures or ingestion of T3-containing preparations should be admitted in anticipation of pending toxicity.
  • Admit all symptomatic patients and place them on cardiac monitoring.
  • Symptomatic patients require correction of dehydration and control of hyperthermia.
  • Important treatment points:
    • Ipecac syrup is no longer recommended for home or hospital treatment.
    • Asymptomatic patients should not be treated empirically with beta-blockers.
    • Chronic overdose—withdraw drug.
    • Use acetaminophen for fever control; aspirin is contraindicated because it displaces T4 from thyroid-binding globulin (TBG), increasing free T4.
    • Because of the delayed conversion to T3 and distribution to tissues, patients must be observed and managed for a longer period of time, especially with large overdoses.
    • The hypothalamic-pituitary-thyroid axis will return to normal in 6-8 weeks.
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Consultations

Consult the regional poison control center or local medical toxicologist (certified through the American Board of Medical Toxicology or the American Board of Emergency Medicine) for additional information and patient care recommendations.

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Contributor Information and Disclosures
Author

Lisandro Irizarry, MD, MPH, FAAEM  Chair, Department of Emergency Medicine, Brooklyn Hospital Center; Assistant Professor, Department of Emergency Medicine, Weill Cornell School of Medicine

Lisandro Irizarry, MD, MPH, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Medical Toxicology, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Nadine A Youssef, MD  Assistant Professor of Emergency Medicine, Tufts University, Department of Emergency Medicine

Nadine A Youssef, MD is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, Emergency Medicine Residents Association, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Anton A Wray, MD, FACEP  Clinical Assistant Professor of Emergency Medicine, Weill Cornell Medical College; Assistant Residency Director, Department of Emergency Medicine, Brooklyn Hospital Center

Anton A Wray, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians and American Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Jeffrey Glenn Bowman, MD, MS  Consulting Staff, Highfield MRI

Disclosure: Nothing to disclose.

John T VanDeVoort, PharmD  Regional Director of Pharmacy, Sacred Heart and St Joseph's Hospitals

John T VanDeVoort, PharmD is a member of the following medical societies: American Society of Health-System Pharmacists

Disclosure: Nothing to disclose.

Fred Harchelroad, MD, FACMT, FAAEM, FACEP  Director of Medical Toxicology, Allegheny General Hospital

Disclosure: Nothing to disclose.

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

Asim Tarabar, MD  Assistant Professor, Director, Medical Toxicology, Department of Emergency Medicine, Yale University School of Medicine; Consulting Staff, Department of Emergency Medicine, Yale-New Haven Hospital

Disclosure: Nothing to disclose.

References

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  2. Bronstein AC, Spyker DA, Cantilena LR Jr, Green JL, Rumack BH, Giffin SL. 2008 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 26th Annual Report. Clin Toxicol (Phila). Dec 2009;47(10):911-1084. [Medline]. [Full Text].

  3. Litovitz TL, White JD. Levothyroxine ingestions in children: an analysis of 78 cases. Am J Emerg Med. Jul 1985;3(4):297-300. [Medline].

  4. Golightly LK, Smolinske SC, Kulig KW, Wruk KM, Gelman CJ, Rumack BH. Clinical effects of accidental levothyroxine ingestion in children. Am J Dis Child. Sep 1987;141(9):1025-7. [Medline].

  5. 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.

  6. Bauer LA. Simulations of Levothyroxine Bioavailability Using a Single-Dose Study Protocol. Am J Ther. Jun 1995;2(6):414-416. [Medline].

  7. Berkner PD, Starkman H, Person N. Acute L-thyroxine overdose; therapy with sodium ipodate: evaluation of clinical and physiologic parameters. J Emerg Med. May-Jun 1991;9(3):129-31. [Medline].

  8. Bosse GM, Matyunas NJ. Delayed toxidromes. J Emerg Med. Jul-Aug 1999;17(4):679-90. [Medline].

  9. Lehrner LM, Weir MR. Acute ingestions of thyroid hormones. Pediatrics. Mar 1984;73(3):313-7. [Medline].

  10. Mariotti S, Martino E, Cupini C, Lari R, Giani C, Baschieri L, et al. Low serum thyroglobulin as a clue to the diagnosis of thyrotoxicosis factitia. N Engl J Med. Aug 12 1982;307(7):410-2. [Medline].

  11. Seger D. Endocrine principles. In: Goldfrank L, ed. Goldfrank's Toxicologic Emergencies. 5th ed. New York, NY: McGraw-Hill; 1994:338-90.

  12. Singh GK, Winterborn MH. Massive overdose with thyroxine,--toxicity and treatment. Eur J Pediatr. Jan 1991;150(3):217. [Medline].

  13. Tunget CL, Clark RF, Turchen SG, Manoguerra AS. Raising the decontamination level for thyroid hormone ingestions. Am J Emerg Med. Jan 1995;13(1):9-13. [Medline].

 
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