12-phase flow (10)

1. 1FRAME
   Thyroid storm with HTN-emergency overlap = catecholamine + thyroid hormone excess + autonomic instability + dehydration → severe HTN + AFib-RVR + decompensated HF + hyperthermia + AMS in patient with hyperthyroidism (Graves, toxic MNG, toxic adenoma, RAI exposure) + identifiable precipitant. Pharmacology pivot: BB FIRST IV (propranolol or esmolol — blunts adrenergic surge + reduces T4→T3 conversion); thionamide PTU PREFERRED in storm (additional T4→T3 block); potassium iodide (Lugol or SSKI) ≥1 h AFTER thionamide (avoids substrate loading); HYDROCORTISONE 100 mg IV q8h (block T4→T3 + cover relative adrenal insufficiency); cholestyramine 4 g PO QID (binds enterohepatic T4); aggressive cooling; AVOID ASA (displaces T4 from TBG). Route to parent engine for shared HTN-emergency arc; this dossier owns the thyroid-cascade pharmacology + multi-organ assessment.
   inputs: sbp, dbp, heart_rate, temperature, mental_status
   advance: BWPS ≥45 OR Akamizu definite criteria + HTN crisis confirmed
2. 2ENTRY
   Recognize storm pentad (hyperthermia + tachyarrhythmia + HTN + HF + AMS); calculate BWPS — score ≥45 = storm; 25-44 impending; <25 unlikely; identify precipitant (infection #1, recent thyroid surgery, RAI, contrast, DKA, MI, trauma, parturition, sudden thionamide cessation)
   inputs: age, sbp, temperature, heart_rate, mental_status
   advance: IV access × 2 + a-line + cardiac monitor + cooling initiated
3. 3CONTEXT
   Hyperthyroid hx (Graves dx? duration? on thionamide?); recent precipitant; medication review (recent ASA — increases free T4; recent IV contrast — Jod-Basedow); allergy (PTU/MMI sulfa cross-reactivity, iodine); pregnancy (PTU first trimester preferred for fetal teratogenicity)
   inputs: age
   advance: precipitant identified + thyroid hx + reproductive hx documented
4. 4RED_FLAGS
   Refractory hyperthermia >40 (life-threat); cardiogenic shock from high-output failure or AFib-RVR; PTU-induced fulminant hepatitis (RUQ pain + bili rise); thionamide-induced agranulocytosis (fever + sore throat + ANC <500); ICH from severe HTN; aspiration from AMS; AVOID ASA, AVOID over-aggressive cooling causing shivering (catechol surge)
   inputs: sbp, temperature, mental_status
   actions: htn_emergency
   advance: RED flags screened + BB + thionamide + hydrocortisone initiated
5. 5INITIAL_WORKUP
   TSH + free T4 + free T3 + total T3; LFT (PTU baseline + hepatic involvement); CBC + diff (thionamide agranulocytosis baseline + infection); BMP + Mg + Ca + glucose; lactate (high-output state); ECG (AFib? QTc?); CXR (pulm edema, infection); blood + urine cultures (precipitant); cortisol (adrenal insufficiency screening)
   inputs: tsh_free_t4_free_t3, lft_with_bilirubin, creatinine, cbc_with_diff, ecg
   actions: panel.cardiac, panel.renal
   advance: workup sent + thyroid cascade initiated
6. 6BRANCHING_WORKUP
   Echo (high-output failure + LV function + valvular + pericardial); thyroid US (Graves vs toxic MNG vs adenoma — affects definitive plan); RAI uptake & scan only AFTER iodine washout (typically deferred); precipitant workup (CT for occult infection, troponin, blood cultures, urine cultures, dental eval)
   inputs: echo
   advance: underlying thyroid disease characterized + precipitant identified
7. 7TREATMENT
   CASCADE (sequenced): (1) BB IV FIRST — propranolol 1-2 mg IV q15 min titrate + 60-80 mg PO q4h once tolerated OR esmolol 50-300 mcg/kg/min infusion (preferred if HF/asthma — short half-life); (2) THIONAMIDE — PTU 200 mg PO/PR q4h PREFERRED in storm (also blocks peripheral T4→T3 conversion) OR methimazole 30-40 mg PO/NG q6h (longer half-life, less hepatotox but slower onset); (3) POTASSIUM IODIDE ≥1 h AFTER thionamide — Lugol 5 drops PO q8h OR SSKI 5 drops PO q8h (Wolff-Chaikoff effect blocks hormone release; iodine before thionamide loads substrate → worsens storm); (4) HYDROCORTISONE 100 mg IV q8h (blocks T4→T3 conversion + covers relative adrenal insufficiency); (5) CHOLESTYRAMINE 4 g PO QID (binds enterohepatic T4 circulation); (6) HTN/AFib management — BB titration is primary HTN control + rate control; nicardipine IV if BP refractory after BB; rate control AFib with BB (avoid CCB if HF); cardioversion if hemodynamic instability; (7) Supportive — aggressive cooling (acetaminophen — NOT ASA; cooling blankets; ice packs; sedate to prevent shivering); IV fluids (volume-depleted from hypermetabolism); empiric abx if infection suspected; treat precipitant. AVOID: ASA (displaces T4 from TBG worsens free hormone), amiodarone (iodine load + cardiotoxic), beta-agonist bronchodilators (catechol surge).
   inputs: sbp, dbp, heart_rate, temperature, creatinine
   advance: cascade initiated + BP controlled + temperature trending down
8. 8DISPOSITION
   ICU mandatory for hyperthermia + AMS + a-line BP + telemetry; endocrine + cardiology + ID consults; dialysis if refractory (plasmapheresis can also reduce circulating hormone); definitive thyroid therapy planning (RAI vs surgery once euthyroid)
   advance: ICU bed assigned + endocrine + cardiology + ID consults booked
9. 9MONITORING
   A-line BP q15-60 min; continuous ECG + temperature; q4-6h BMP + Mg + Ca; daily LFT (PTU hepatotox); q3d CBC with diff (thionamide agranulocytosis); free T4 + T3 q24h to track normalization; daily neuro exam; precipitant resolution tracking
   inputs: sbp, temperature, creatinine
   actions: panel.cardiac
   advance: BWPS trending down + hyperthermia resolving + AFib rate-controlled + LFT/CBC stable
10. 10FOLLOWUP
    Definitive thyroid therapy when euthyroid (4-6 wk) — RAI ablation OR thyroidectomy (surgery preferred if compressive goiter, suspicious nodule, severe ophthalmopathy, pregnancy plans, or RAI failure); lifelong levothyroxine post-definitive; endocrinology long-term; AVOID future precipitants (educate); MedicAlert; family screening for autoimmune thyroid
    advance: definitive therapy plan + lifelong endocrine follow-up booked