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endo.thyroid-storm.core.v1

Thyroid storm

endocrinologyacuteadultpregnancyacuteinpatient
Start encounter →Print handoutPRODUCTION

No problem-package folder under src/lib/tier3/problem-package/packages/ for thyroid storm — design brief + atoms not yet authored. Manifest references calc_burch_wartofsky / calc_qtc which are not yet in clinical-tools-registry.ts; only generic calc.qsofa available. panel.thyroid in registry already embeds Burch-Wartofsky scoring as part of 5-pattern matrix — reused as primary risk-stratification surface. Regimen_axes empty — thionamide/β-blocker/iodine/steroid orchestration not yet exposed as a structured RegimenAxis.

Entry points (3)

  • symptom
    Hyperpyrexia + sinus tach/AF + AMS
    fever_tachycardia_ams
  • lab_abnormality
    Suppressed TSH + markedly elevated FT4/FT3
    severe_hyperthyroidism
  • problem_list
    Known Graves with infection / surgery / iodine load
    graves_decompensated

Required inputs (11)

  • agerequired
    demographic • used at CONTEXT
    Elderly + apathetic storm presentation; pregnancy alters drug choice (PTU 1st trimester)
  • core_temperaturerequired
    vital • used at RED_FLAGS
    Hyperpyrexia drives BWPS; cooling intervention
  • hrrequired
    vital • used at RED_FLAGS
    Tachycardia / AF drives β-blocker selection
  • sbprequired
    vital • used at RED_FLAGS
    Shock + HF complication of storm; affects esmolol vs propranolol choice
  • tshrequired
    lab • used at INITIAL_WORKUP
    Suppressed TSH essential
  • ft4required
    lab • used at INITIAL_WORKUP
    Markedly elevated; correlates with severity
  • ft3required
    lab • used at INITIAL_WORKUP
    T3 toxicosis subset; PTU blocks T4→T3 conversion
  • lft
    lab • used at INITIAL_WORKUP
    Hepatic dysfunction is BWPS criterion; PTU hepatotoxicity baseline
  • graves_or_nodularrequired
    history • used at CONTEXT
    Etiology drives long-term plan (RAI vs surgery)
  • pregnancy_statusrequired
    history • used at CONTEXT
    1st trimester PTU > methimazole; MFM + neonatology
  • current_meds
    medication • used at CONTEXT
    Amiodarone, recent iodinated contrast (precipitates AIT/Jod-Basedow), checkpoint inhibitor

12-phase flow (12)

  1. 1FRAME
    Recognize storm pattern (BWPS ≥45 or JTA criteria) in thyrotoxic patient; impending storm 25-44 still requires aggressive therapy
    inputs: core_temperature, hr
    advance: storm threshold crossed by BWPS or clinical gestalt
  2. 2ENTRY
    Capture trigger (hyperpyrexia + tach + AMS, severe lab pattern, decompensated Graves)
    inputs: age
    advance: trigger captured
  3. 3CONTEXT
    Capture etiology (Graves / nodular / amio-induced / factitious), pregnancy status, recent iodine exposure, current antithyroid drug + adherence
    inputs: graves_or_nodular, pregnancy_status, current_meds
    advance: etiology classified; precipitant identified
  4. 4RED_FLAGS
    Hyperpyrexia >40°C, AF with rapid response, HF, hepatic failure, AMS/coma, shock (Burch-Wartofsky 1993; JES 2016)
    inputs: core_temperature, hr, sbp
    actions: calc.qsofa
    advance: red flags screened; ICU triggered
  5. 5INITIAL_WORKUP
    TSH, FT4, FT3, total T3/T4, TRAb, CBC (PTU/MMI agranulocytosis baseline), CMP, LFT, lactate, troponin, CK, BNP; ECG; CXR; cultures; β-hCG
    inputs: tsh, ft4, ft3, lft
    actions: panel.thyroid, panel.hormone, panel.cardiac, workup.thyroid_storm
    advance: baseline endocrine + cardiac + hepatic labs sent
  6. 6BRANCHING_WORKUP
    Etiology workup post-stabilization: TRAb (Graves), thyroid US (nodular), avoid radioiodine uptake during acute storm; AIT 1 vs 2 if amiodarone
    actions: workup.hyperthyroidism_deep
    advance: etiology workup queued
  7. 7DIFFERENTIAL
    Phenotype: Graves decompensated, toxic nodular goiter, amiodarone-induced (type 1 vs 2), factitious thyrotoxicosis, postpartum thyroiditis storm; rule out sepsis / NMS / serotonin syndrome / pheo
    advance: phenotype assigned
  8. 8RISK_STRATIFICATION
    Burch-Wartofsky Point Scale ≥45 highly suggestive; 25-44 impending; <25 unlikely; JTA TS1/TS2 alternate; QTc surveillance
    actions: calc.qsofa
    advance: BWPS computed; severity classified; ICU disposition decided
  9. 9TREATMENT
    PTU 500-1000 mg load PO/NG → 250 mg q4h (also blocks T4→T3) [pregnancy 1st trimester] OR methimazole 60-80 mg/day; β-blocker (propranolol 60-80 mg q4h or esmolol if HF); iodine (SSKI 5 drops q6h or Lugol) ≥1h AFTER thionamide; hydrocortisone 100 mg IV q8h; cooling (acetaminophen — NOT aspirin); supportive ICU care; cholestyramine for refractory; plasmapheresis last-line
    inputs: hr, sbp, pregnancy_status
    advance: thionamide + β-blocker + iodine + steroid + cooling + supportive in flight
  10. 10DISPOSITION
    ICU mandatory; endocrinology day 1; surgery consult for definitive plan once stabilized (4-8 wk thionamide bridge)
    advance: ICU + consults secured
  11. 11MONITORING
    Continuous telemetry, q1h vitals + temp, q24-48h TSH/FT4/FT3, q-weekly CBC for agranulocytosis on PTU/MMI, daily LFT for PTU hepatotoxicity, QTc on ECG
    inputs: hr, core_temperature, lft
    actions: panel.thyroid, panel.lft
    advance: storm resolving (BWPS <25 + clinical improvement)
  12. 12FOLLOWUP
    Endocrinology + thyroid ultrasound; plan definitive therapy (RAI or thyroidectomy after 4-8 wk antithyroid stabilization); ophthalmopathy assessment; agranulocytosis education
    advance: definitive therapy plan + follow-up scheduled