EM · Endocrine emergencies

Thyroid emergencies — thyroid storm and myxoedema coma

Also known as Thyroid storm · Thyrotoxic crisis · Myxoedema coma · Myxedema coma · Severe decompensated hypothyroidism

Thyroid storm (the thyrotoxic crisis) is the rare, life-threatening decompensation of thyrotoxicosis producing a hypermetabolic state of tachycardia, hyperthermia, agitation, atrial fibrillation and high-output heart failure, graded by the Burch-Wartofsky score. Myxoedema coma is its mirror image: severe decompensated hypothyroidism presenting as hypoventilation, hypothermia, bradycardia, hyponatraemia and coma. Thyroid storm is treated with beta-blockade (propranolol 60 to 80 mg orally every 4 hours or esmolol IV), propylthiouracil 500 mg loading then 250 mg every 4 hours, Lugol iodine 8 drops every 6 hours started at least 4 hours after the PTU, hydrocortisone 100 mg IV every 8 hours, cooling and fluids. Myxoedema coma is treated with levothyroxine 200 to 500 mcg IV loading, hydrocortisone 100 mg IV, and supportive care with ventilation and active rewarming. Both are clinical diagnoses treated empirically before the thyroid function result returns. ACEM-primary, globally tagged.