You are called to review a 48-year-old male in the post-operative recovery unit (PACU) who has just undergone resection of a TSH-secreting pituitary adenoma via a trans-sphenoidal approach. He is febrile (38.5°C) and is hypertensive (160/50 mmHg) with tachycardia (130 beats/min) and hyper-dynamic circulation, and is hyper-reflexic.
Give the likely diagnosis. (10% marks)
List your immediate pharmacological management. (30% marks)
a) Thyroid storm
b) Propranolol 60-80mg 4-6 hourly (or other beta blocker) to control BP and HR Propylthiouracil (200mg 4hrly) or Carbimazole 20-30 mg every 4-6 hours Hydrocortisone 100mg 6hrly
The patient clearly demonstrates many classic features of hyperthyroidism:
The intuitive candidate will leap immediately to the conclusion that this is a TSH release mediated thyroid storm, as seen in one case report every ten years or so. How being able to identify this zebra diagnosis discriminates good intensivists from bad, one can only guess.
Pharmacological management of thyroid storm consists of the following steps: