Tasty Morsels of EM 131 – #FRCEM Thyroid Emergencies

26 Aug

I’m entering a few months prep for the UK and Ireland exit exam in Emergency Medicine: the FRCEM. I’ll be adding lots of little notes on pearls I’ve learned along the way. A lot of my revision is based around the Handbook of EM as a curriculum guide and review of contemporary, mainly UK guidelines. I also focus on the areas that I’m a bit sketchy on. With that in mind I hope they’re useful.

You can find more things on the FRCEM on this site here.

Some good FOAMed on this

What is a thyrotoxic crisis?

  • thyroid hormones are T3 and T4
  • when these are in dramatic excess for a variety of reasons then you get thyroid storm
  • most T3 and T4 is bound to protein and inactive. T3 is the more active one.
  • thyroid hormones regulate metabolism and also the expression and sensitivity of beta receptors making them equisitively sensitive to endogenous beta agonists. Hence why you get a sympathomimetic picture in someone with a precipitant that stimulates endogenous catecholamines
  • presentation
    • fever
    • altered mental status
    • sympathetic surge
    • background of hyperthyroidism (mainly Grave’s)
  • clinical diagnosis but if you have them high T3/4 and low/undetectable TSH. Also another cause of high calcium

How should we manage it?

  • usual resus stuff
  • control the sympathetic surge – propanolol or esmolol (as per OHEM)
  • steroids (reduce conversion of T4 to T3 and also treat the commonly co existent adrenal insufficiency)
  • Propylthiouracil (PTU) or Carbimazole (both block new production)
    • don’t give aspirin as apparently this displaces thyroid hormone from it’s binding making it active.

What happens in severe hypothyroidism?

From LITFL and Rosen’s 8th

  • female
  • more often in winter
  • usually long standing hypothyroidism
  • hypothermic
  • altered mental status – lethargy, confused, coma
  • hypotension/bradycardia
  • type II RF common
  • myxoedmea facies (puffy eyes and nose and tongue)
  • if you can get it a sky high TSH in the right context would be useful

How should we manage it?

  • big doses of thyroid hormone
    • in the young ones give the T3
    • in the older folk give the T4
  • steroids again – for the adrenal insufficiency


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