What is the emergency management of overt hyperthyroidism?

Emergency Management of Overt Hyperthyroidism

Beta-blockers (e.g., atenolol or propranolol) are the first-line treatment for emergency management of overt hyperthyroidism, along with supportive care and hydration, while initiating appropriate definitive therapy based on the underlying cause. 1

Initial Assessment and Stabilization

Clinical Presentation

• Assess for symptoms of severe thyrotoxicosis:
  • Tachycardia, palpitations, arrhythmias (especially atrial fibrillation)
  • Hyperthermia, diaphoresis
  • Agitation, tremor, anxiety
  • Nausea, vomiting, diarrhea
  • Dehydration
  • Weight loss
  • Heat intolerance

Immediate Management

1. Beta-blockers:

   • Start with propranolol 20-40mg every 4-6 hours or atenolol 25-50mg daily 1
   • Titrate to control heart rate and adrenergic symptoms
   • Contraindicated in severe asthma, uncontrolled heart failure

2. Supportive Care:

   • Intravenous fluids for dehydration
   • Cooling measures for hyperthermia
   • Cardiac monitoring for arrhythmias
   • Oxygen supplementation if needed

Severity-Based Management

Grade 1 (Mild/Asymptomatic)

• Continue beta-blockers for symptomatic relief
• Monitor thyroid function every 2-3 weeks 1
• Can continue immune checkpoint inhibitors if that's the cause

Grade 2 (Moderate Symptoms)

• Consider holding immune checkpoint inhibitors if that's the cause
• Beta-blockers for symptomatic relief
• Hydration and supportive care
• Consider endocrine consultation 1

Grade 3-4 (Severe Symptoms)

• Hold immune checkpoint inhibitors if that's the cause
• Mandatory endocrine consultation
• Beta-blockers
• Hydration and supportive care
• Consider hospitalization
• Consider additional therapies:
  • Thionamides (methimazole or propylthiouracil)
  • Saturated solution of potassium iodide (SSKI)
  • Glucocorticoids in severe cases 1

Thyroid Storm (Life-Threatening Hyperthyroidism)

Thyroid storm is a rare but potentially fatal complication requiring immediate intensive care:

1. Immediate Interventions:

   • ICU admission
   • Aggressive cooling
   • IV fluids
   • Cardiac monitoring

2. Medication Protocol:

   • Beta-blockers (IV propranolol if necessary)
   • Thionamides (methimazole 20-25mg every 6 hours or propylthiouracil 200-250mg every 4 hours) 2
   • Iodine solution (SSKI) 1 hour AFTER thionamides
   • High-dose glucocorticoids (dexamethasone 2mg IV every 6 hours)
   • Treat precipitating factors (infection, trauma, etc.)

Diagnostic Workup (Concurrent with Treatment)

• TSH, free T4, and T3 levels
• Complete blood count
• Basic metabolic panel
• Liver function tests
• Consider TSH receptor antibody testing if Graves' disease is suspected 1
• ECG to assess for arrhythmias

Etiology-Specific Considerations

Graves' Disease

• Most common cause (70% of hyperthyroidism cases) 3
• Consider methimazole as first-line antithyroid drug 2, 4
• Avoid methimazole in first trimester of pregnancy due to teratogenic risk 2

Toxic Nodular Goiter

• Accounts for approximately 16% of hyperthyroidism cases 3
• Less responsive to antithyroid drugs
• Definitive treatment with radioiodine or surgery typically required 3

Thyroiditis

• Self-limited in most cases
• Supportive care with beta-blockers
• NSAIDs for pain if inflammatory 1

Special Considerations

Pregnancy

• Propylthiouracil preferred in first trimester
• Switch to methimazole in second and third trimesters 2
• Avoid radioactive iodine (absolutely contraindicated)
• Beta-blockers can be used cautiously

Elderly Patients

• More susceptible to cardiovascular complications
• Start with lower doses of medications
• Monitor closely for adverse effects

Follow-up

• Monitor thyroid function tests every 2-3 weeks initially
• Watch for transition to hypothyroidism in thyroiditis cases 1
• Adjust medications based on clinical response and laboratory values

Common Pitfalls to Avoid

1. Failing to recognize thyroid storm as a medical emergency
2. Using iodine before thionamides (can worsen hyperthyroidism)
3. Not monitoring for agranulocytosis with thionamide therapy
4. Overlooking the need to adjust doses of other medications (anticoagulants, digitalis, theophylline) as thyroid status normalizes 2
5. Missing the diagnosis of central hypothyroidism (low TSH with low free T4) 1