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Ovid: Oxford Handbook of Acute Medicine

Editors: Ramrakha, Punit S.; Moore, Kevin P. Title: Oxford Handbook of Acute Medicine, 2nd Edition Copyright ©1997,2004 Oxford University Press (Copyright 1997, 2004 by Punit S Ramrakha and Kevin P Moore) > Table of Contents > Chapter 9 – Endocrine emergencies > Thyrotoxic crisis: assessment Thyrotoxic crisis: assessment The term thyrotoxic crisis refers to a constellation of symptoms and signs which together imply a poor prognosis. Thyroid function tests provide no discrimination between simple thyrotoxicosis and thyrotoxic crisis. If the diagnosis has not been made, look for clues such as a goitre, or exophthalmic Graves’ disease. The presentation may be confused with sepsis or malignant hyperthermia. Presentation Cardiovascular symptoms

  • Palpitations
  • Tachycardia/tachyarrhythmias
  • Cardiac failure/oedema

CNS Symptoms

  • Anxiety/agitation
  • Violent outbursts
  • Psychosis/delirium
  • Fitting/coma

Gastrointestinal symptoms

  • Diarrhoea
  • Vomiting
  • Jaundice

General symptoms

  • Fever
  • Hyperventilation
  • Sweating
  • Polyuria

Precipitants of thyrotoxic crisis

  • Thyroid surgery/general surgery
  • Withdrawal of anti-thyroid drug therapy/radioiodine therapy
  • Thyroid palpation
  • Iodinated contrast dyes
  • Infection
  • Cerebrovascular accident/pulmonary embolism
  • Parturition
  • Diabetic ketoacidosis
  • Trauma or emotional stress.

Investigations

  • Thyroid function tests (most labs can perform an urgent TSH/free T4 if needed)
  • U&Es (?dehydration)
  • Calcium (may be elevated)
  • Glucose (may be low)
  • FBC
  • Liver function tests (?jaundice)
  • Blood and urine cultures
  • CXR (?pulmonary oedema or evidence of infection)
  • ECG (rate, ?atrial fibrillation).

Assessment of severity

  • The table opposite is used to assess the severity of a thyrotoxic crisis.
  • Rarely, patients may present with an apathetic thyroid storm, and lapse into coma with few other signs of thyrotoxicosis.

P.591

Assessment of severity of a thyrotoxic crisis
Temp (°C) Score Pulse Cardiac failure CNS effects GI symptoms  
Apyrexial <99 Absent Normal Normal 0
>37.2 >99 Ankle oedema — — 5
>37.8 >110 Basal creps. Agitation Diarrhoea, vomiting 10
>38.3 >120 Pulmonary oedema — — 15
>38.9 >130 Delirium Unexplained jaundice 20
>39.4 >140 — — 25
>40 Coma, seizure — 30
  • Add the scores for each column.
  • Add an extra 10 points if atrial fibrillation is present.
  • Add 10 points if there is a definable precipitant.
  • A total score of over 45 indicates thyroid crisis; a score of 25–44 indicates impending crisis.

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