UC Irvine Journal of Education and Teaching in Emergency Medicine Title Thyroid Storm Permalink https://escholarship.org/uc/item/2hs7z6c1 Journal Journal of Education and Teaching in Emergency Medicine, 4(3) ISSN 2474-1949 Authors Ferretti, Natalie Yee, Jennifer Publication Date 2019 DOI 10.5070/M543044546 License https://creativecommons.org/licenses/by/4.0/ 4.0 Peer reviewed eScholarship.org Powered by the California Digital Library University of California SIMULATION Thyroid Storm * * Natalie Ferretti, MD and Jennifer Yee, DO *The Ohio State University, Department of Emergency Medicine, Columbus OH Correspondence should be addressed to Jennifer Yee, DO at [email protected] Submitted: January 10, 2019; Accepted: May 15, 2019; Electronically Published: July 15, 2019; https://doi.org/10.21980/J8XD03 Copyright: © 2019 Ferretti, et al. This is an open access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) License. See: http://creativecommons.org/licenses/by/4.0/ Empty Line Calibri Size 12 Empty Line Calibri Size 12 ABSTRACT: Audience: This simulation is designed to educate emergency medicine residents and medical students on the recognition and management for thyroid storm. Introduction: Hyperthyroidism is a condition in which the thyroid gland produces too much thyroid hormone. This can usually be controlled with medications; however, 1%-2% of patients will develop thyroid storm, which is a life-threatening condition. If not treated emergently, thyroid storm can lead to end-organ damage and cardiovascular collapse.1 Thyroid storm has a nonspecific presentation with signs and symptoms including hyperpyrexia, tachycardia, central nervous system (CNS) dysfunction, and gastrointestinal (GI) manifestations; all of these mimic many other more common emergency department (ED) presentations.2 Therefore, it is important for medical providers to recognize associated symptoms, have a high suspicion for the diagnosis based on patient presentation, and quickly provide necessary treatment to stabilize the patient. Educational Objectives: By the end of this simulation session, the learner will be able to: 1) understand the essential physical exam components necessary to evaluate for etiologies of acute encephalopathy, 2) review laboratory and imaging studies to obtain for evaluation of acute encephalopathy and/or suspected thyroid storm, as well as the rationale behind ordering each study, 3) identify underlying etiologies or pathologies for developing thyroid storm, 4) discuss treatment for thyroid storm. Educational Methods: This session is conducted using high-fidelity simulation, followed by a debriefing session on evaluation for and treatment of thyroid storm. However, it could also be run as an oral boards case. Research Methods: Our residents are provided a survey at the completion of the debriefing session so they may rate different aspects of the simulation, as well as provide qualitative feedback on the scenario. Results: Feedback was largely positive, with a potential broad differential and specific treatment regimen cited as beneficial to review. The residents voiced appreciation at seeing a photograph of the patient’s face at the beginning of the case, as the ophthalmopathy was difficult to reproduce on the mannequin. 1 SIMULATION Discussion: This is a cost-effective method for reviewing thyroid storm. Learners had a wide range of narrow versus broad differentials, as well as comfort level with treatment. Having the pharmacist unavailable to answer their questions caused them to rely on alternative sources of knowledge, typically, their cell phones. Our main take-away is to continue providing visual stimuli to enhance a physical exam in order to bolster psychological buy-in. Topics: Medical simulation, endocrine emergencies, thyroid disorders, thyroid storm, hyperthyroidism. 2 USER GUIDE List of Resources: workup to narrow the differential (objective 2). Learners will Abstract 1 need to identify possible underlying etiologies (objective 3) and User Guide 3 initiate treatment (objective 4). Afterwards, there will be discussion about the etiology, pathophysiology, and mechanism Instructor Materials 5 of action of the pharmacologic treatment of thyroid storm Operator Materials 16 (objectives 1-4). Debriefing and Evaluation Pearls 18 Simulation Assessment 20 Recommended pre-reading for instructor: We recommend that instructors become familiar with the 2016 Learner Audience: American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism.1 Other suggested reading Medical students, interns, junior residents, senior residents includes the materials listed below under Time Required for Implementation: “References/suggestions for further reading.” Instructor Preparation: 30 minutes Time for case: 20 minutes Results and tips for successful implementation: Time for debriefing: 30 minutes This simulation was written to be performed as a high-fidelity simulation scenario but may also be used as a mock oral board Recommended Number of Learners per Instructor: case. We conducted this scenario approximately twelve times 3-4 for fifty emergency medicine residents broken into groups of four during August-September 2018. The residents voiced Topics: appreciation at seeing a photograph of the patient’s face at the Medical simulation, endocrine emergencies, thyroid beginning of the case, as the ophthalmopathy was difficult to disorders, thyroid storm, hyperthyroidism. reproduce on the mannequin. Depending on the desired level of autonomy, faculty may inform learners their pharmacist is at Objectives: lunch, so they are unable to ask them recommended doses and By the end of this simulation session and debriefing, the instead must look them up on smart phones or provided learner will be able to: computers. We typically do not allow pharmacists in simulation cases to make clinical suggestions, but may provide dosages for 1. Understand the essential physical exam rarely-used medications. components necessary to evaluate for etiologies of acute encephalopathy. References/suggestions for further reading: 2. Review laboratory and imaging studies to obtain for 1. Ross DS, Burch HB, Cooper DS, et al. 2016 American evaluation of acute encephalopathy and/or Thyroid Association guidelines for diagnosis and suspected thyroid storm, as well as the rationale management of hyperthyroidism and other causes of behind ordering each study. thyrotoxicosis. Thyroid. 2016;26(10):1343-1421. doi: 3. Identify underlying etiologies or pathologies for 10.1089/thy.2016.0229. developing thyroid storm. 2. Stathatos N, Wartofsky L. Thyrotoxic storm. J Intensive Care 4. Discuss treatment for thyroid storm. Med. 2002;17(1):1–7. doi: 10.1046/j.1525- 1489.2002.17002.x. 3. Bacuzzi A, Dionigi G, Guzzetti L, Martino AI, Severgnini P, Linked objectives and methods: Cuffari S. Predictive features associated with thyrotoxic Thyroid storm is an uncommon ED presentation, and many of storm and management. Gland Surg. 2017;6(5):546-551. the symptoms are consistent with much more common ED doi: 10.21037/gs.2017.07.01. diagnoses. The most important tool for diagnosis of this life- 4. Wang HI, Yiang GT, Hsu CW, Wang JC, Lee CH, Chen YL. threatening condition is having a high clinical suspicion. This Thyroid storm in a patient with trauma – a challenging simulation scenario allows learners to review the patient diagnosis for the emergency physician: case report and presentation, highlights the importance of the prehospital literature review. J Emerg Med. 2017;52(3):292–298. doi: history and of obtaining pertinent past medical history and a 10.1016/j.jemermed.2016.09.003. current medication list. Learners will have the opportunity to 5. Chiha M, Samarasinghe S, kabaker AS. Thyroid storm. J perform initial assessment and provide appropriate Intensive Care Med. 2015;30(3):131–140. doi: resuscitation of a critically ill patient (objective 1). They will 10.1177/0885066613498053. work through a differential diagnosis for life-threatening causes of altered mental status and order appropriate tests and eturn: Calibri Size 10 Ferretti N, et al. Thyroid Storm. JETem 2019. 4(3):S1-24. https://doi.org/10.21980/J8XD03 3 USER GUIDE 6. Zull, D. Thyroid and adrenal disorders. In: Marx JA, Hockberger RS, Walls RM, eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 7th ed. Mosby Elsevier: Philadelphia, PA; 2010. p. 1150-1164. 7. Yoshida D. Thyroid storm precipitated by trauma. J Emerg Med. 1996;14(6):697-701. 8. Franklyn JA, Boelaert k. Thyrotoxicosis. Lancet. 2012;379(9821):1155-1166. doi: 10.1016/S0140- 6736(11)60782-4. 9. Bhattacharyya A, Wiles PG. Thyrotoxic crisis presenting as acute abdomen. J R Soc Med. 1997;90(12):681-682. 10. De Leo S, Lee SY, Braverman LE. Hyperthyroidism. Lancet. 2016;388(10047):906-918. doi: 10.1016/S0140- 6736(16)00278-6. 11. Sabir AA, Sada k, Yusuf BO, Aliyu I. Normothermic thyroid storm: an unusual presentation. Ther Adv Endocrinol Metab. 2016;7(4):200–201. doi: 10.1177/2042018816657701. 12. Satoh T, Isozaki O, Suzuki A, et al. 2016 Guidelines for the management of thyroid storm from The Japan Thyroid Association and Japan Endocrine Society (first edition). Endocr Journal. 2016;63(12):1025-1064. doi: 10.1507/endocrj.EJ16-0336. 13. Garber JR, Greenlee MC, Klein I, et al. Hyperthyroidism and other causes of thyrotoxicosis: management guidelines of the American Thyroid Association and American Association of Clinical Endocrinologists. Thyroid. 2011;21(6):593-646. doi: 10.1089/thy.2010.0417.