Emergency Medicine App

Evidence-based EM & critical care, one topic at a time.

[Emergency Medicine App @EmergencyMedApp]

Fair point, and an important one: storm isn't just bad hyperthyroidism, and the drug you reach for to slow the heart can be what tips it over.

The uncomfortable part: the entire playbook rests on zero randomized trials. Here's what the numbers actually show. 🧵

[Dr. Chacón-Lozsán F .'. @franciscojlk]

Thyroid storm in the ICU: when controlling tachycardia can precipitate cardiovascular collapse

Thyroid storm is not simply severe hyperthyroidism. It is a life-threatening hypermetabolic crisis characterized by cardiovascular, neurological and systemic organ dysfunction.

The 2026 joint consensus endorsed by the European Thyroid Association and other endocrine societies provides important guidance for critical care.

The first challenge is recognition.

Thyroid hormone concentrations may overlap with uncomplicated thyrotoxicosis. Diagnosis is clinical, supported by Burch–Wartofsky and Japanese criteria.

Fever, disproportionate tachycardia, atrial fibrillation, altered consciousness and gastrointestinal dysfunction should raise suspicion, particularly after infection, surgery or trauma.

Reported mortality ranges from approximately 8% to over 30%.

The second challenge is cardiovascular physiology.

Thyroid hormone increases metabolic demand and adrenergic responsiveness. Tachycardia may initially sustain cardiac output, but persistent cardiovascular stress can progress to cardiomyopathy and cardiogenic shock.

Beta-blockade is fundamental, yet potentially dangerous.

In patients with impaired systolic function, abruptly suppressing sympathetic compensation may precipitate circulatory collapse.

Early echocardiography is therefore essential. In unstable patients, carefully titrated, short-acting esmolol may be preferable to prolonged beta-blockade.

Treatment must interrupt several mechanisms simultaneously.

High-dose methimazole, carbimazole or propylthiouracil inhibits hormone synthesis. PTU additionally reduces peripheral T4 to T3 conversion, although available observational evidence does not demonstrate superior survival compared with methimazole.

Hydrocortisone reduces peripheral conversion and supports management of potential adrenal insufficiency.

Iodide suppresses thyroid hormone release, but should be administered at least one hour after antithyroid medication to avoid potentially worsening thyrotoxicosis.

Supportive care includes cooling, appropriate fluid management, treatment of precipitants and organ support. Aspirin should be avoided for antipyresis.

What happens when conventional treatment fails?

Reassess drug absorption, ongoing triggers and cardiovascular dysfunction.

Cholestyramine may enhance hormone clearance. Therapeutic plasma exchange can provide temporary control, while emergency thyroidectomy offers definitive treatment in selected refractory cases.

VA-ECMO may provide a bridge to endocrine recovery or definitive treatment in refractory cardiogenic shock, although evidence remains limited.

Reference 📚
Taylor P et al. 2026. European Thyroid Journal. https://t.co/37BvJweRCF

#CriticalCare #ThyroidStorm #EndocrineEmergency #CardiogenicShock #IntensiveCare

[Emergency Medicine App @EmergencyMedApp]

@amalmattu Likely why, not proven: most resting tone is the internal sphincter. That smooth muscle makes over 70% of resting anal pressure itself, with sympathetic input (PMID 30827084). Sacral roots drive the external sphincter, so tone can feel normal with a numb saddle. Educational only.

[Emergency Medicine App @EmergencyMedApp]

@amalmattu The anal tone data back you. Meta-analysis (6 studies, n=741): sensitivity 0.23 to 0.53. In 996 ED patients sent for MRI, rectal findings had no link to compression; bilaterally absent ankle jerks did (OR 2.9). What still delays the scan? Educational only.
https://t.co/24TJZ5T8oH

[Emergency Medicine App @EmergencyMedApp]

Full evidence, including induction agents and paralytics: https://t.co/QvB0UaiAH4

Photo: DiverDave, Wikimedia Commons, CC BY 3.0

[Emergency Medicine App @EmergencyMedApp]

Worth bookmarking. In critically ill adults, seeing the cords is often the easier half of the job. Keeping saturation and blood pressure up from induction to tube confirmation is where patients get hurt.

Thread: four studies on that window and the physiology behind each.

[Critical Care Reviews @CritCareReviews]

In-hospital emergency airway management in critically ill patients: a narrative review

CCR Journal Watch
https://t.co/Sp06oA6IDG

[Emergency Medicine App @EmergencyMedApp]

7/ Bottom line: oxygen with pressure before induction, gentle breaths after it, and a plan for the blood pressure drop that same pressure can cause.

What's your default preoxygenation for the hypoxemic patient: NRB, HFNC or NIV?

Educational, not medical advice.

[Emergency Medicine App @EmergencyMedApp]

@shahshowkat07 Insulin moves K into cells by switching on Na-K-ATPase, mostly in muscle. Total body K doesn't fall, so it rebounds. Glucose drops later: insulin can outlast 25 g dextrose, and failing kidneys clear less insulin and make less glucose. Onset ~2 h; check to 6 h. Educational only.

[Emergency Medicine App @EmergencyMedApp]

@shahshowkat07 Good save at K 8.87. Hypoglycemia is the harm to watch after that. In 675 ED patients with renal insufficiency, insulin 5 vs 10 units: 19.5% vs 28.6% hypoglycemia, same K drop (-1.0 mEq/L). Retrospective data. Still giving 10? Educational only. https://t.co/zfbBxEpESJ

[Emergency Medicine App @EmergencyMedApp]

@francisdeng Consolidation: exudate or other disease product replaces alveolar air. An air bronchogram means air is gone, by resorption (atelectasis) or replacement (pneumonia). Density rarely says which (PMID 18195376). Low pretest odds sink PPV even at 94% specificity. Educational only.

[Emergency Medicine App @EmergencyMedApp]

@francisdeng Imaging shows airless lung, not infection. In an ED meta-analysis, ultrasound consolidation was 82% sensitive and 94% specific for pneumonia, in patients already suspected of it. So who should write the word pneumonia? Educational only. https://t.co/XDtHa94ITv

[Emergency Medicine App @EmergencyMedApp]

@IM_Crit_ Why minutes matter: CPR is low flow. In 160 Minnesota ECPR patients, pH fell and lactate and PaCO2 rose as CPR ran longer; neuro-intact survival fell too, even on ECMO (PMID 31896278). INCEPTION's median arrest-to-flow was 74 min. OnScene wasn't randomized. Educational only.

[Emergency Medicine App @EmergencyMedApp]

@IM_Crit_ Flow time is the story, and the RCTs fit it. ARREST (n=30): 43% vs 7% survival to discharge. INCEPTION (n=134): 20% vs 16% good neuro outcome at 30 days, not significant. Is the benefit the circuit or the minutes to flow? Educational only. https://t.co/CZrtMtLTMa

[Emergency Medicine App @EmergencyMedApp]

Full evidence: https://t.co/D6bPXCeBtQ

[Emergency Medicine App @EmergencyMedApp]

Shift teaching: ADD-RS is 1. D-dimer is 320 ng/mL. What next? Commit to an answer before flipping the page. Evidence in the reply.

[Emergency Medicine App @EmergencyMedApp]

Why D-dimer helps: dissection triggers clotting; plasmin breaks down cross-linked fibrin, releasing D-dimer. A negative result lowers probability with low clinical risk—not alone. False negatives occur. High suspicion still needs urgent evaluation.