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

Authors: Erik D. Schraga, MDAuthor Information and Disclosures

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.

Miscellaneous

Medical/Legal 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.
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Hyperthyroidism, Thyroid Storm, and Graves Disease excerpt

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Author Information and Disclosures

Author: Erik D. Schraga, MD, Consulting Staff, Permanente Medical Group, Kaiser Permanente, Santa Clara Medical Center

Coauthor(s): Craig A. Manifold, DO, Associate Program Director, Department of Emergency Medicine, Wilford Hall Medical Center

Erik D Schraga, MD, is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Emergency Medicine Residents' Association

Editor Information

Robin R Hemphill, MD, MPH, Associate Professor, Director, Disaster Preparedness, Department of Emergency Medicine, Vanderbilt University Medical Center; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Howard A Bessen, MD, Professor of Medicine, UCLA School of Medicine; Program Director, Department of Emergency Medicine, Harbor-UCLA Medical Center; John Halamka, MD, Chief Information Officer, CareGroup Healthcare System, Assistant Professor of Medicine, Department of Emergency Medicine, Beth Israel Deaconess Medical Center; Assistant Professor of Medicine, Harvard Medical School; and Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital

 
 
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