Differentiating Between Thyrotoxicosis and Thyroid Storm: Burch-Wartofsky Score. Treatment Goals: Inhibition of New Thyroid Hormone. address these diagnostic challenges, the Burch-Wartofsky Point Scale (BWPS) for diagnosis of thyroid storm and impending thyroid storm was pro- posed in. The Burch-Wartofsky Point Scale (BWPS) for diagnosis of TS, proposed in , is an empirically derived scoring system, which considers the.
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Thyroid storm TS is an endocrine emergency characterized by rapid deterioration, associated with high mortality rate therefore rapid diagnosis and emergent treatment is mandatory.
In the past, thyroid surgery was the most common cause of TS, but recent preoperative medication creates a euthyroid state wagtofsky performing surgery. An active approach during perioperative period could determine an effective clinical treatment of this life-threating diseases.
Recently, the Japan Thyroid Association and Japan Endocrine Society developed diagnostic criteria for TS wartofzky on premature and prompt diagnosis avoiding inopportune e useless drugs. This review analyses predictive features associated with thyrotoxic storm highlighting recent literature to wartofsku the patient quality of care. In a recent manuscript, the TS is estimated to be 0. Occurrence is main frequent into female gender with a ratio female: Additionally, pregnancy and post-partum period are triggering factors to develop TS due to redefinition of autoimmunity state 4.
Nowadays, thyroid surgery is the mainly endocrine procedures carried out in the world 5 and the hyperactivity of thyroid tissue after sub-total thyroidectomy is the primarily aetiology of perioperative TS.
It can also occur during the intra-op period as a result of uncontrolled follicular cells secretion. Otherwise, the onset rate correlated to endocrine surgery is decreasing according to recent preoperative indications that create an euthyroid state before performing surgery 6.
Therefore, an unsuitable preoperative management is related to a disastrous outcome during preoperative, intraoperative and postoperative periods. The classical features of TS such as abdominal pain, diarrhoea, nervousness and restlessness are masked during general anaesthesia and only hyperthermia wartlfsky cardiovascular effects could be the life threatening signs 7.
Several conditions could simulate an inappropriate thyroid function and differential diagnoses [anaphylactic reaction, malignant hyperthermia, brain insult, phaeochromocytoma, neuroleptic malignant syndrome or untreated hypertension 8 ] could determine an inappropriate management delay.
More rarely other thyrotoxic disorders, such as destructive thyroiditis, toxic multinodular goiter, TSH-secreting pituitary adenoma, hCG-secreting hydatidiform mole or metastatic thyroid cancer, cause TS 9 – Triggering conditions could be drugs such as amiodarone, sorafenib, ipilimumab and inappropriate hormone ingestion 13 – 15 or medical settings as surgery, radioiodine therapy and exposure to excess iodine in patients with hyperthyroidism 2516 For these reasons, in all patients with know or unknown abnormal thyroid function submitted to surgical procedures is necessary to assess the compliance to the prescribed therapy and to optimize hormonal secretion, to settle the better endocrinal function at hospitalization.
During preoperative period a complete physical exam, focusing on cardiovascular signs, could suggests a clinical suspicion for thyrotoxicosis permitting to prevent perioperative systemic organ failure related to inappropriate hormonal excretion.
Acute heart failure is the initial event, followed by respiratory failure, disseminated intravascular coagulation DICgastrointestinal signs, neurological collapse and sepsis 3.
To reduce mortality and to improve survival rate early suspicion, prompt diagnosis and intensive treatment on presentation of TS are essential The Japan Thyroid Association and Japan Endocrine Society taskforce committee conducted nationwide surveys and developed new diagnostic criteria for TS, in addition to Burch and Wartofsky scale 3 The guidelines for the management of TS in order to increase the accuracy of clinical diagnosis recommend use of both diagnostic systems to evaluate patients Criteria Burch-Wartofsky point scale Diagnostic criteria for thyroid storm 3.
The presentation of TS includes fever, profuse sweating, signs of encephalopathy anxiety, emotional lability, restlessness, agitation, confusion, delirium, frank psychosis, comavarious cardiac manifestations sinus tachycardia, atrial arrhythmias, congestive heart failuresystolic hypertension, and gastrointestinal symptoms diffuse abdominal pain with abnormal liver enzymes levels The major challenges of an intraoperative TS onset are due to several conditions that could mimic a cardiovascular collapse with thermoregulatory signs such as pain, electrolytes disturbances, malignant hyperthermia, heart failure and anaphylactic reactions 7.
The pillar of TS management is to treat the hormonal excess excretion starting prematurely all supportive maneuvers.
Admission into intensive care unit ICU is recommended for all patients, not only when heart failure, haemostatic disorders and multiple organ failure are occurred but also to optimize physiological conditions. The intraoperative approach recently published 18 appears the finest method to treat this disorder.
Thionamides, propylthiouracil PTU and methimazole MMIare the mainstays to control the activity of increased thyroid hormone levels. The main action of Waetofsky is the direct inhibition of thyroid wartofdky in the thyroid gland, with reduction of synthesis of new hormone.
Inorganic iodide inhibiting iodide oxidation and organification the Wolff-Chaikoff effect. It is widely used as pre-operatory treatment for thyroid surgery in order to decrease intraoperative bleeding, because inorganic iodide can reduce blood flow to the thyroid gland Inorganic iodide should be administered simultaneously with ATDs in patients with TS with hyperthyroidism condition.
The hypermetabolic state related to Buech could generate a depletion of stress hormones and corticosteroids should be administered as prophylaxis for related adrenal insufficiency.
Archive: Burch-Wartofsky thyroid storm score
Additionally, Bianco et al. The restoration of thermoregulation is mandatory to reduce all deleterious effects on coagulation, electrolytes balance and pH.
Acetaminophen is the first choice and all mechanical refrigeration techniques such as cooling blankets or ice packs should be used in TS patients with resistant fever. Infections, with fever onset, could manifest TS 2 and a precocious antibiotic therapy has to be applied on patients with suspected thyroid disease before sepsis signs are evident The treatment of hyperdynamic state related to inappropriate hormonal excretion is through beta-adrenergic receptor antagonist drugs.
The principal drugs to treat supraventricular arrhythmias are endovenous landiolol and esmolol. In patients with severe pulmonary disease, such as asthma and COPD, verapamil or diltiazem are the better choice. When supraventricular tachycardia occurred with impaired hemodynamic status is necessary to proceed to cardioversion.
Indeed, digitalis is useful in patients with normal renal function without hemodynamic failure. TS can lead to acute congestive heart failure CHF. In this setting, respiratory management should include non-invasive positive pressure ventilation NIPPVor tracheal intubation according to neurologic, pulmonary and cardiac functional status.
Administration of endovenous vasoactive drugs and diuretics should be considered in order to maintain cardiovascular tone, to reduce venous return. The use of extracorporeal supportive maneuvers is rare. Additionally, neurologic manifestation is common 3 ; to treat disturbances of consciousness and psychosis the psychiatrist or neurologist consultation to select doses of psychotropic medications should be considered When convulsions are present, benzodiazepines are first-line agents.
Alternative drugs for resistant convulsions are fosphenytoin, phenobarbital and sodium thiopental Figure 2 Nowadays, the patients with central nervous manifestations and age major to 60 years have a higher mortality.
There is an increased risk of gastrointestinal haemorrhage, due to corticosteroids administration, coagulopathy and mechanical ventilation 3. Acid-suppressive drugs, such as proton pump inhibitors PPIs or histamine-2 receptor antagonists H2Asare recommended Hepatic failure is not a rare complication. The emergency thyroidectomy could be the only solution to treat such complications and appropriate life support is suggested 19 including therapeutic plasmapheresis and haemodialysis The above-mentioned literature shows that TS is a life threating medical conditions due to excessive hormonal activity.
Actually, TS is a dangerous expression of thyrotoxicosis precipitated by several events. The presence of heart collapse, coagulation abnormalities and organ failure determines a poor outcome and all the therapeutic strategies are involved to reduce hormonal activity, to prevent organ damage and to sustain vital capacity.
All the supportive measures employed during preoperative, intraoperative and postoperative periods are directed to avoid complications. Therefore, a thyroid function investigation should be performed in every patient with abnormal findings, such as tachycardia, weight loss, and tremors.
The physicians wartofsy not to delay all the necessary treatment when there is a clinical suspicion to increase quality care of TS patients, in order to improve the outcome. The authors have no conflicts of interest to declare. National Center for Biotechnology InformationU. Journal List Gland Surg v. Author information Article notes Copyright and License information Disclaimer. I Conception and design: All authors; VII Final approval of manuscript: Received Jun 5; Accepted Jun Copyright Gland Surgery.
Abstract Thyroid storm TS is an endocrine emergency characterized by rapid deterioration, associated with high mortality rate therefore rapid diagnosis and emergent treatment is mandatory. Thyroid storm TSthyroidectomy, management, wartofky storm. Table 1 Criteria Burch-Wartofsky point scale monitoring: Open in a separate window. Thyrotoxic storm management The pillar of TS management is to treat the hormonal excess excretion starting prematurely all supportive maneuvers.
Inorganic iodide Inorganic iodide inhibiting iodide oxidation and organification the Wolff-Chaikoff effect. Corticosteroids The hypermetabolic state related to TS could generate a depletion of stress hormones and corticosteroids should be administered as prophylaxis for related adrenal insufficiency.
Antipyretics The restoration of thermoregulation is mandatory to reduce all deleterious effects on coagulation, electrolytes balance and pH. Beta-adrenergic receptor antagonists beta-AAS Wartofdky treatment of hyperdynamic state related to inappropriate hormonal excretion is through beta-adrenergic receptor antagonist drugs.
Algorithm for the treatment of convulsion in patients with thyroid storm. Conclusions The above-mentioned literature shows that TS is a life threating medical conditions due to excessive hormonal activity. Footnotes Conflicts of Interest: Mortality, morbidity and long-term results in surgically treated hyperthyroid patients. Review of cases. Acta Chir Scand ; Med Clin North Am ; Diagnostic criteria, clinical features, and incidence of thyroid storm based on nationwide surveys.
Thyroid storm during pregnancy. Crit Care Nurse ; Current indications for thyroidectomy.
Minerva Chir ; Thyroid storm during thyroidectomy of the thyrotoxicosis patient. Korean J Anesthesiol ; Bajwa SJ, Sehgal V. Anesthesia and thyroid surgery: The never ending challenges. Indian J Endocrinol Metab ; Anesthetic implications of concurrent diseases. A rare case of subacute thyroiditis causing thyroid storm.