2.  44 y/o patient with Graves’ Dx  Recently cleared for total thyroidectomy  The surgical H&P:  AF VSS WNL RRR no m/r/g CTAB

3.  Vitals: 101.9 167 153/86 26  Agitation  Scleral icterus  Bilateral crackles with expiratory wheezing  Palpitations  Mild diaphoresis and nausea without emesis  No obstruction of airway 2 /2 goiter

4.  Thyrotoxic vs. Thyroid Storm  Life-threatening complication Mortality with Tx 8% or below  Most cases occur post-op Within 6-18 hrs Why? Pre-op Tx necessary?  Si/Sx varied but consider… Hyperdynamic Metabolism  SITT DD are common triggers  Burch and Wartofsky Score ≥ 45 highly suggestive of thyroid storm ≤ 25 thyroid storm unlikely

5.  Temp: 99-99.9 5 points 100-100.9 10 points ≥ 104.0 30 points  Tachycardia 90-109 5 points 110-119 10 points 120-129 15 points ≥140 25 points  A. Fib Absent 0 points Present 10 points  Precipitating Event Absent 0 points Present 10 points  CHF Absent 0 points Mild (pedal edema) 5 points Moderate (bb rales) 10 points Severe(pulm edema) 15 points  CNS Absent 0 points Mild 10 points Moderate 20 points Severe 30 points  GI-Hepatic Absent 0 points Moderate 10 points Severe 20 points

6.  Pre-op euthyroidism Goiter? Patients with tachycardia and HTN  consider cancellation  Iodide Sodium Iodide, Iopanoic acid, Lugol’s solution ○ Block the release of hormone ○ Wolff-Chaikoff effect  Beta-Blocker  Cortisol Adrenal function?  Thionamides PTU favored for decrease in peripheral conversion  Cholestyramine  Temp control  Hydration With or without glucose?

7.  Nerve damage Superior Laryngeal ○ Motor to Cricothyroid mm.  aspiration Recurrent Laryngeal ○ Everything laryngeal except Cricothyroid  Hoarseness, stridor, total airway obstruction  Hypoparathyroidism Laryngospasm  Hypothyroidism  Tracheal Compression

9.  “Big Blue”  Nayak B., Burman K.: Thyrotoxicosis and Thyroid Storm. Endocrinology and Metabolism Clinics 35. (4): 2006.  Pearce E., Braverman L.: Hyperthyroidism: advantages and disadvantages of medical therapy. Surgical Clinics of North America 84. (3): 2004.  Franklyn JA.: The Management of Hyperthyroidism. New England Journal of Medicine 330 (24): 1731-8. 1994 abstract.  Burch H.B., Wartofsky L.: Life-threatening thyrotoxicosis. Thyroid Storm. Endocrinology and Metabolism Clinics of North America 22: 263-277. 1993. abstract.