Severe Hyperthyroidism: Thyrotoxicosis and Thyroid Storm (Nursing)

00:01 Now we're going to talk about severe hyperthyroidism.

00:04 So thyrotoxicosis and thyroid storm.

00:08 So first let me explain the key differences between thyrotoxicosis and thyroid storm. In Thyrotoxicosis, this refers to any state of thyroid hormones that has an excess. So it represents the broader condition of hyperthyroidism.

00:21 Now it can be mild to moderate in severity.

00:24 It usually develops gradually and it's often manageable with outpatient treatment.

00:29 They have generally stable vital signs and the patient is usually alert and oriented.

00:34 That is thyroidtoxicosis.

00:36 Remember, it's just kind of the broader condition of hyperthyroidism.

00:40 Thyroid storm, on the other hand, is the most severe form of thyroid toxicosis. It is a life threatening medical emergency.

00:49 Now this is going to look very different.

00:50 There's going to be extreme elevation of the thyroid hormones.

00:53 There's going to be multiple organs that are decompensating.

00:57 The heart rate is going to be a severe tachycardia, usually above or often above 140 beats a minute.

01:03 They're going to have a high high fever greater than 102 Fahrenheit or 39 Celsius. They are going to be severely agitated or have an altered mental status.

01:13 And if this keeps going without being treated, they can have cardiovascular collapse.

01:18 Now, a thyroid storm requires immediate ICU admission, and this can actually cause the patient's death if it's not able to be managed.

01:26 Now there's usually some precipitating event infection, surgery or some type of trauma.

01:31 And this is often seen as a decompensation of previously controlled thyrotoxicosis. So why does this matter? Because you want to educate your patients and you always want to be aware a patient with hyperthyroidism is at risk for this.

01:46 So as we wrap this up, think of it this way: Thyrotoxicosis is like a car that's running too fast.

01:52 That engine is just revving.

01:54 Thyroid storm is like that same car's engine overheating and all the systems failing at once.

02:01 Thyroid storm is essentially thyrotoxicosis that has become severely decompensated. Always keep in mind a patient with hyperthyroidism is at risk for both.

02:13 Let's dive in deep to the treatment plan for thyrotoxicosis and thyroid storm. Now, I want you to think of a comprehensive treatment approach for a thyroid storm. So, you know overall we're thinking about immediate stabilization of ABC. So airway management if you need it, oxygen support, IV fluids, cardiac monitoring.

02:32 Definitely going to be in the ICU admission.

02:35 But I want to break it down for you as we continue this conversation.

02:39 First of all, we want to stop any new hormone synthesis.

02:43 Now PTU is preferred over methimazole in order to block new hormone synthesis. Here's the reason why PTU blocks T4 to T3 conversion peripherally.

02:54 That's really good. So you're going to give a large loading dose.

02:57 Then you're going to give frequent dosing. Because remember our goal is to block new hormone synthesis. Next we want to block sympathetic effects.

03:05 So beta blockers are the drug of choice for this propanolol is typically the one that's preferred. Now beta blockers like propranolol do two things.

03:14 It will block peripheral conversion of T4 to T3, and it will also control the heart rate in sympathetic symptoms.

03:21 Now this can be given IV if the symptoms are severe enough, but you're going to use the beta blocker to block the sympathetic effects of the thyroid storm. Now, this one might surprise you.

03:32 You may not have thought of corticosteroids in the management of a thyroid storm, so I want to break down why corticosteroids are crucial in thyroid storm treatment. Now adrenal insufficiency is an increased risk when a client has a thyroid storm because in a thyroid storm, there's an extremely high metabolic demand.

03:51 The adrenal glands just may not be able to keep up with the cortisol needs.

03:55 And also hyperthyroidism increases cortisol metabolism and clearance.

04:00 So without enough cortisol, patients can develop an adrenal crisis.

04:04 So giving the corticosteroids will help prevent this adrenal crisis.

04:09 Now we also want to block T4 to T3 conversions.

04:12 So as we continue in this discussion of corticosteroids you're going to see that they play several key roles.

04:18 Now we know that T4 has to be converted to T3 in peripheral tissues.

04:23 But corticosteroids can also help block this conversion.

04:27 Now it's important because T3 is way more potent than T4.

04:30 So anytime we can reduce T3 this will help decrease the thyroid hormones.

04:35 So corticosteroids help block this conversion and they work along the other side medications like PTU. Now what about the anti-inflammatory effects of corticosteroids? Well, they're also helpful.

04:46 That can help you reduce the fever of your client.

04:49 It can decrease systemic inflammation.

04:51 And that's particularly important as thyroid storms often has inflammatory triggers. Now what about the stress response.

04:59 Well thyroid storm is an extreme physiological stress.

05:03 The body needs more cortisol during severe illness.

05:06 So corticosteroids ensure adequate stress response which will help maintain the blood pressure and support glucose metabolism.

05:13 So you can see why corticosteroids are a key component of thyroid storm treatment.

05:18 They address both the direct thyroid hormone excess and supporting the body's stress response systems. So hydrocortisone or dexamethasone these are the drugs that will block peripheral conversion of T4 to T3 and help treat that potential adrenal insufficiency and help with the client's fever.

05:35 As we wrap up the treatment plan for thyroid storm, let's talk about the supportive care.

05:41 Now you're going to want to do aggressive cooling if the patient is really high fever. You're also going to want to look at what caused this, because you're going to need to treat the underlying cause, the precipitant, could be infection or any one of the possible triggers.

05:55 You're going to have to watch their electrolytes closely and manage those.

05:59 Also, keep an extra close eye on the glucose monitoring and be thoughtful about DVT prophylaxis.

06:06 Now, we said that a thyroid storm will cause you to be in intensive care.

06:09 So you'll have continuous cardiac monitoring.

06:12 So until they are stabilized, you're going to do extremely frequent vital signs and keep a close eye on their mental status.

06:19 So you're going to want to do consistent and serial mental status checks.

06:23 And of course you're going to want to do thyroid function tests and monitor all of the other systems. So there's a key point as we finish here.

06:32 Treatment must be rapid and aggressive as thyroid storm has a high mortality rate even with proper treatment.