A 56-year-old woman is brought to the emergency department after several hours of severe nausea, vomiting, palpitations, and altered mental status. She was diagnosed with Graves' hyperthyroidism 6 months ago and received methimazole, which was stopped 2 months ago due to a skin rash. The patient was treated with radioactive iodine (RAI) 3 days ago. She was not taking any medications before this admission. She does not use tobacco or alcohol.
On examination, the patient is agitated and confused. Temperature is 39.4 C (103 F), blood pressure is 160/90 mm Hg, pulse is 160/min, and respirations are 24/min. Pulse oximetry is 98% on room air. The thyroid is diffusely enlarged but nontender. The patient has a fine hand tremor and mild lid lag. The lungs are clear to auscultation. Her abdomen is soft and nontender. She has no muscle rigidity, and deep tendon reflexes are 2+ bilaterally throughout. Laboratory results are as follows:

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Which of the following is the best next step in management of this patient?

Question

A 56-year-old woman is brought to the emergency department after several hours of severe nausea, vomiting, palpitations, and altered mental status.  She was diagnosed with Graves' hyperthyroidism 6 months ago and received methimazole, which was stopped 2 months ago due to a skin rash.  The patient was treated with radioactive iodine (RAI) 3 days ago.  She was not taking any medications before this admission.  She does not use tobacco or alcohol.
On examination, the patient is agitated and confused.  Temperature is 39.4 C (103 F), blood pressure is 160/90 mm Hg, pulse is 160/min, and respirations are 24/min.  Pulse oximetry is 98% on room air.  The thyroid is diffusely enlarged but nontender.  The patient has a fine hand tremor and mild lid lag.  The lungs are clear to auscultation.  Her abdomen is soft and nontender.  She has no muscle rigidity, and deep tendon reflexes are 2+ bilaterally throughout.  Laboratory results are as follows:

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Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec193a_95fa_01fb_853d_9f52354d28ec_MD0002_00 This patient's presentation suggests thyroid storm, a life-threatening thyrotoxicosis triggered by a specific event (eg, surgery, trauma, infection) or acute iodine load. The risk of thyroid storm is increased in patients with undiagnosed or inadequately treated hyperthyroidism, especially following withdrawal or noncompliance with anti-thyroid medication. Initial clinical features may include nausea and vomiting, often associated with fever, tachycardia, hypertension, tremor, lid lag, and altered mentation. Complications include seizures, hepatic injury (elevated liver transaminases), cardiac arrhythmias (eg, atrial fibrillation), and congestive heart failure leading to hypotension and shock. Thyroid markers (decreased TSH, increased T₄) in thyroid storm are similar to those in uncomplicated hyperthyroidism, and so the diagnosis must be made clinically. Treatment includes beta blockers (eg, propranolol) for heart rate control and a thionamide (eg, methimazole, propylthiouracil) to block new hormone synthesis. ₄ Radioiodine therapy can trigger thyroid storm. Pretreatment with a thionamide and/or beta blocker before administration of radioiodine should be considered for elderly patients and those with extensive comorbidity or severe pre-treatment thyrotoxicosis to reduce the risk of thyroid storm. Although agranulocytosis with any thionamide is a contraindication to future thionamide therapy, patients who develop a rash on methimazole may receive propylthiouracil (and vice versa). (Choice A) Blood cultures and empiric antibiotics would treat bacteremia and sepsis, which usually present with fever, hypotension, and tachycardia. This patient's elevated blood pressure makes this less likely. (Choice B) Dantrolene is given to treat malignant hyperthermia, a hypermetabolic syndrome due to volatile anesthetics (eg, isoflurane) with or without succinylcholine. Susceptible patients typically develop hypercarbia, sinus tachycardia, generalized muscle rigidity, elevated creatine kinase, and hyperthermia. (Choice C) Glucocorticoids (eg, dexamethasone) are given later in the treatment of thyroid storm to decrease peripheral T₄ to T₃ conversion and improve vasomotor stability. ₄ ₃ (Choice D) Lorazepam can be used to treat alcohol withdrawal, which usually presents with tachycardia, hypertension, fever, and altered mental status. This patient has no history of heavy alcohol use. Educational objective: Thyroid storm is a life-threatening thyrotoxicosis in patients with undiagnosed or incompletely treated hyperthyroidism. Patients can develop tachycardia, hypertension, cardiac arrhythmias, fever, tremor, and altered mentation. Treatment includes beta blockers and a thionamide (eg, propylthiouracil). __________ References: Thyroid storm: an updated review. (http://www.ncbi.nlm.nih.gov/pubmed/23920160)

A 56-Year-Old Woman Is Brought to the Emergency Department After