What are the guideline sources, guidelines and references for Thyroid storm ?
Guideline sources The following summarized guidelines for the evaluation and management of thyroid storm are prepared by our editorial team based on guidelines from the American Society for Apheresis (ASFA 2019), the European Thyroid Association (ETA 2018), the American Thyroid Association (ATA 2016), and the Japan Thyroid Association (JTA/JES 2016). 1 2 3 4 Calculator Calculator Burch-Wartofsky Point Scale for Diagnostic Criteria for Thyroid S Guidelines 1. Screening and diagnosis Diagnostic criteria: As per ATA 2016 guidelines: Diagnose thyroid storm clinically in a severely thyrotoxic patient with evidence of systemic decompensation. B https://web.pathway.md/diseases/reccp88l0GiE86c8O 1/5 6/24/23, 4:06 PM Thyroid storm Pathway Consider using a sensitive diagnostic system (such as the Burch-Wartofsky Point Scale) as an adjunct to diagnosis. B As per JTA 2016 guidelines: Suspect thyroid storm in patients with high fever ( 38 C), marked tachycardia ( 130 bpm) and symptoms originating from multiple organ systems, such as the CNS, cardiovascular system and gastrointestinal tract. B Use the diagnostic criteria for thyroid storm for initial evaluation of airway, breathing, circulation, dysfunction of CNS and exposure and environmental control (ABCDE) and treatment in patients with suspected thyroid storm. B 2. Classification and risk stratification Risk stratification: As per ATA 2016 guidelines, risk stratify patients using a validated scale. Patients with a Burch- Wartofsky Point Scale of 45 and evidence of systemic decompensation require aggressive therapy. The decision to use aggressive therapy in patients with a Burch-Wartofsky Point Scale of 25-44 should be based on clinical judgment. B As per JTA 2016 guidelines, consider using the APACHE II or SOFA scores for the prognostic prediction in patients with thyroid storm. C 3. Medical management Setting of care: transfer patents with highly suspected thyroid storm based on diagnostic criteria to a general hospital with an ICU and specialists in endocrinology and other subspecialties. B Show 2 more General principles: As per ETA 2018 guidelines, ensure a multimodality treatment approach in patients with thyroid storm, including antithyroid drugs, corticosteroids, and -blockers. B As per ATA 2016 guidelines, ensure a multimodality treatment approach in patients with thyroid storm, including -blockers, antithyroid drug therapy, inorganic iodide, and corticosteroids in patients with thyroid storm. B As per JTA 2016 guidelines, ensure a multimodality approach with antithyroid drugs, inorganic iodide, corticosteroids, -blockers, and antipyretic agents to ameliorate thyrotoxicosis and its adverse effects on multiple organ systems. B Pharmacotherapy, antithyroid drugs: As per ATA 2016 guidelines, administer propylthiouracil 500-1,000 mg PO load, then 200 mg every 4 hours in patients with thyroid storm. Consider administering IV. As per JES/JTA 2016 guidelines: https://web.pathway.md/diseases/reccp88l0GiE86c8O 2/5 6/24/23, 4:06 PM Thyroid storm Pathway Administer antithyroid drugs, either methimazole or propylthiouracil, for the treatment of hyperthyroidism in thyroid storm. B Administer IV methimazole in severely ill patients with consciousness disturbances or impaired gastrointestinal tract function. B Pharmacotherapy, corticosteroids: As per ATA 2016 guidelines, administer corticosteroids such as hydrocortisone 300 mg IV load, then 100 mg every 8 hours in patients with thyroid storm. As per JES/JTA 2016 guidelines, administer corticosteroids (300 mg/day hydrocortisone or 8 mg/day dexamethasone) in patients with thyroid storm regardless of its origin. B Pharmacotherapy, beta-blockers: As per ATA 2016 guidelines, administer -blockers such as propranolol 60-80 mg PO every 4 hours in patients with thyroid storm. As per JES/JTA 2016 guidelines, initiate selective -1 blockers (IV landiolol, esmolol, or PO bisoprolol) as first-line therapy for tachycardia in thyroid storm. Consider choosing other PO selective -1 blockers as well. Do not use nonselective -blocker propranolol for the treatment of tachycardia in thyroid storm, although it is not contraindicated. B Show 7 more Pharmacotherapy, inorganic iodide: As per ATA 2016 guidelines, administer inorganic iodide such as saturated solution of potassium iodide 0.25 mL or 250 mg PO every 6 hours, given 1 hour after propylthiouracil in patients with thyroid storm. As per JES/JTA 2016 guidelines, administer inorganic iodide simultaneously with antithyroid drugs in patients with thyroid storm caused by thyrotoxic diseases associated with hyperthyroidism. B Supportive care: As per ETA 2018 guidelines, provide supportive care in patients with thyroid storm, including cooling blankets, volume resuscitation, nutritional support, respiratory care, and monitoring in an ICU. B As per ATA 2016 guidelines, provide supportive care in patients with thyroid storm, including cooling blankets, volume resuscitation, nutritional support, and respiratory care and monitoring in an ICU, as appropriate for an individual patient. B As per JTA 2016 guidelines: Initiate aggressive cooling with acetaminophen and mechanical cooling with cooling blankets or ice packs in patients with high fever. B Evaluate the focus of infection in patients with high fever and treat the accompanying infection. B Management of complications (atrial fibrillation): administer IV digitalis at an initial dose of 0.125-0.25 mg when AF occurs in patients without severe renal dysfunction, followed by an https://web.pathway.md/diseases/reccp88l0GiE86c8O 3/5 6/24/23, 4:06 PM Thyroid storm Pathway appropriate maintenance dose with careful monitoring for signs and symptoms of digitalis toxicity. B Show 3 more Management of complications (acute heart failure): Obtain hemodynamic monitoring using a Swan-Ganz catheter in patients with Killip class III acute congestive HF. B Proceed to cardiopulmonary bypass before the development of irreversible multiple organ failure when hemodynamic status has not improved with the maximum dose of adrenergic agonists. B Management of complications (DIC): initiate intensive treatment for DIC as patients with thyroid storm complicated with DIC has an increased risk of mortality. B Management of complications (CNS manifestations): Obtain differential diagnosis and treat acute disturbances of consciousness, psychosis and convulsion in patients with thyroid storm, in addition to prompt treatment of thyrotoxicosis, based on established guidelines and in consultation with a psychiatrist or neurologist. B Take into account the condition of each patient individually when selecting and adjusting doses of psychotropic medications because thyrotoxicosis and dysfunction of multiple organs, such as the liver and kidney, can affect pharmacokinetics in patients with thyroid storm. B Management of complications (gastrointestinal): recognize that gastrointestinal symptoms including diarrhea, nausea, and vomiting are associated with thyrotoxicosis, HF, neurological disorders, and gastrointestinal infection. Treat gastrointestinal infection in parallel with thyrotoxicosis to improve gastrointestinal symptoms. B Show 2 more 4. Therapeutic procedures Plasmapheresis: as per JTA 2016 guidelines, consider performing therapeutic plasma exchange if clinical improvement is not noted within 24-48 hours of initial treatment with appropriate doses of antithyroid drugs, inorganic iodine, corticosteroids, or -blockers, as well as specific treatment for the triggering disease and complications with thyroid storm. C 5. Preventative measures Prevention: Take care to prevent thyroid storm in patients with poor adherence undergoing antithyroid drug treatment. B Consider offering definitive treatment of Graves' disease, either by radioactive iodine or thyroidectomy, to prevent recurrent thyroid storm in patients successfully managed during the acute stage of thyroid storm. B https://web.pathway.md/diseases/reccp88l0GiE86c8O 4/5 6/24/23, 4:06 PM Thyroid storm Pathway References 1. Ross DS, Burch HB, Cooper DS et al. 2016 American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism and Other Causes of Thyrotoxicosis. Thyroid. 2016 Oct;26 10 1343 1421. Open 2. Tetsurou Satoh, Osamu Isozaki, Atsushi Suzuki et al. 2016 Guidelines for the management of thyroid storm from The Japan Thyroid Association and Japan Endocrine Society First edition). Endocr J. 2016 Dec 30;63 12 1025 1064. Open 3. Anand Padmanabhan, Laura Connelly-Smith, Nicole Aqui et al. Guidelines on the Use of Therapeutic Apheresis in Clinical Practice Evidence-Based Approach from the Writing Committee of the American Society for Apheresis: The Eighth Special Issue. J Clin Apher. 2019 Jun;34 3 171 354. Open 4. Kahaly GJ, Bartalena L, Heged s L et al. 2018 European Thyroid Association Guideline for the Management of Graves' Hyperthyroidism. Eur Thyroid J. 2018 Aug;7 4 167 186. Open 5. Douglas S Ross, Henry B Burch, David S Cooper et al. 2016 American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism and Other Causes of Thyrotoxicosis. Thyroid. 2016 Oct;26 10 1343 1421. Open https://web.pathway.md/diseases/reccp88l0GiE86c8O 5/5