Escaping a storm alive: A case report of a young woman's acute presentation of thyroid storm leading to cardiac arrest salvaged by VA-ECMO
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Journal of Clinical Anesthesia and Chao et al., J Clin Anesth Intensive Care
2021; 2(1): 26-30.
Intensive Care
Case Report
Escaping a storm alive: A case report of a young
woman’s acute presentation of thyroid storm
leading to cardiac arrest salvaged by VA-ECMO
Jennifer Chao1*, Richard Cook2, Vinay Dhingra1
1
Department of Critical Care, Vancouver Abstract
General Hospital, Vancouver, BC,
Canada Thyroid storm is a rare but potentially life-threatening form of thyrotoxicosis. The presence of excessive
thyroid hormones leads to toxic direct and indirect effects on the cardiovascular system resulting in entity
2
Department of Cardiac Surgery, known as thyrotoxicosis-induced cardiomyopathy (TCM). The end stage of TCM results in cardiorespiratory
Vancouver General Hospital, Vancouver, failure from cardiogenic shock and pulmonary edema. Such outcomes have been rescued through
BC, Canada mechanical circulatory support via extracorporeal membrane oxygenation (ECMO). We describe a case of a
previously healthy 35-year-old female who presented de-novo in thyroid storm and rapid atrial fibrillation,
*Author for correspondence: arrested within hours of presentation, was placed emergently on extracorporeal cardiopulmonary
Email: jenchao@alumni.ubc.ca resuscitation (ECPR) via veno-arterial ECMO, and made a full neurological and cardiac recovery. TCM can be
very challenging to treat medically with spiralling effects of tachyarrhythmia and worsening cardiac output
Received date: December 07, 2020 leading to decompensated heart failure. TCM is often reversible once euthyroid physiology is achieved.
Accepted date: March 15, 2021 It also appears to affect relatively younger patients with the average age of about 50 years. Mechanical
support through means of ECMO should be strongly considered in patients presenting in cardiorespiratory
failure from thyroid storm in ECMO-capable centres.
Copyright: © 2021 Chao J, et al. This
is an open-access article distributed
Keywords: Thyroid storm, Cardiac arrest, Extracorporeal membrane oxygenation
under the terms of the Creative
Commons Attribution License, which Introduction
permits unrestricted use, distribution,
and reproduction in any medium, Thyroid storm is potentially a fatal manifestation of thyrotoxicosis. Thyroid storm is rare with
provided the original author and reported incidence of approximately 0.6/100,000 persons per year and occur in relatively young
source are credited. patients with the average age of 50 years [1]. Thyroid storm often presents in patients with underlying
thyroid disease, most commonly being Grave’s disease. Due to the presence of excessive thyroid
hormones, the body transforms into a hypermetabolic state. Clinical presentation can be nonspecific
with signs and symptoms of fever, tachycardia, palpitations, fatigue, dyspnea, and gastrointestinal
upset; but in the most severe cases feature end-organ dysfunction such as hepatic failure, neurological
deterioration and cardiorespiratory failure. Patients with thyrotoxicosis presenting in cardiorespiratory
failure have mortality rates as high as 30% [2]. We report a case of a previously healthy 35-year-
old female who presented to our emergency department (ED) in rapid atrial fibrillation (AF) and
thyroid storm, who then decompensated rapidly into cardiac arrest, was placed on extracorporeal
cardiopulmonary resuscitation (ECPR) via veno-arterial extracorporeal membrane oxygenation (VA-
ECMO) and made a full neurological and cardiac recovery. We will briefly review the pathophysiology
and management of cardiorespiratory failure in thyroid storm, as well as the current literature behind
the utilization of ECMO in such cases.
Case Presentation
Citation: Chao J, Cook R, Dhingra V.
Escaping a storm alive: A case report of A 35-year-old Filipino female walked into our ED with a 2-week history of palpitations, dyspnea
a young woman’s acute presentation and peripheral edema. She was previously healthy, with no past medical history of thyroid disease,
of thyroid storm leading to cardiac and reported no drug abuse or medication use. Her initial vital signs were a heart rate (HR) of 190-
arrest salvaged by VA-ECMO. 2021; 2(1): 220 bpm in rapid AF (ECG shown in Figure 1), blood pressure of 150/70 mmHg, O2 saturation at
26-30. 92% on room air, respiratory rate of 24 and temperature of 37.5°C. Her Burch-Wartofsky Point Scale
This article is originally published by ProBiologist LLC., and is freely available at probiologists.com
J Clin Anesth Intensive Care 2021; 2(1): 26-30. 26Citation: Chao J, Cook R, Dhingra V. Escaping a storm alive: A case report of a young woman’s acute presentation of thyroid storm leading to cardiac arrest salvaged by VA-ECMO. J Clin Anesth Intensive Care. 2021; 2(1): 26-30. Figure1: Initial ECG. was 75. Her bloodwork revealed a TSH that was non-detectable at hospital’s ECPR team was activated. There was return of spontaneous
Citation: Chao J, Cook R, Dhingra V. Escaping a storm alive: A case report of a young woman’s acute presentation of thyroid storm leading to cardiac arrest
salvaged by VA-ECMO. J Clin Anesth Intensive Care. 2021; 2(1): 26-30.
Figure 2: Chest X-Ray post arrest.
syndrome and her right femoral artery was repaired. Her VA-ECMO state. Specifically, during thyrotoxicosis, there is decreased systemic
cannulation sites were swapped from the right femoral artery and vascular resistance leading to decreased afterload, as well as increased
vein to the left femoral artery and vein. By end of Day 2 she was fully preload from fluid and salt retention due to the activation of the
weaned off vasopressor and ionotropic support, her sedation was renin-angiotensin-aldosterone system (RAAS) [3]. Furthermore,
lightened, and she was found to be awake and obeying all four limbs. increased sympathetic activity and excess thyroid hormones at the
cardiomyocytes can lead to excessive chronotropic and ionotropic
By Day 3, she appeared ready for decannulation. A repeat TEE
effects leading to tachyarrhythmias and myocardial ischemia. Lastly,
revealed normal LV function but some persistent RV dysfunction.
the development of rapid AF in thyrotoxicosis can precipitate further
A pulmonary artery (PA) catheter was inserted to further assess her
hemodynamic collapse due to loss of atrial kick, atrioventricular
cardiac function and filling pressures during weaning of VA-ECMO.
synchrony and HR control [4]. If all these mechanisms are not
She was found to have a cardiac index of 4.2 (normal 2.5-4.0 L/
suppressed, the end result is a form of dilated cardiomyopathy
min/m2) and cardiac output of 7.1 L/min (normal 4.0-8.0 L/min)
with impaired systolic and diastolic function, manifesting as
via continuous cardiac output monitoring. A mixed venous oxygen
cardiorespiratory failure from cardiogenic shock and pulmonary
saturation was measured at 80%, pulmonary artery pressures of
edema (Figure 3).
38/15 mmHg, and a central venous pressure of 12 mmHg. She was
successfully decannulated at 65 hours following her initial arrest. The paramount step to treat thyroid storm is making the
correct diagnosis. There is no standard guideline for the diagnosis
Her TSH antibody assay came back positive, confirming the
of thyroid storm; however, two scoring systems have been derived
diagnosis of Grave’s disease. A thyroid ultrasound revealed no
to help facilitate this clinical diagnosis – the Busch and Wartofsky
nodules or masses but only signs of thyroiditis. At Day 7 she was
Point scale and the Japan Thyroid Association Thyroid storm criteria
successfully extubated and tolerated her first run of intermittent
[5]. Following the recognition of thyroid storm, the mainstay
hemodialysis without vasopressor support. On Day 11, a repeat TTE
treatments are to 1) achieve euthyroid state, 2) symptom control
was performed and revealed a normal LVEF at 65% in sinus rhythm
via beta blockade, and 3) provide supportive care to maintain
with a normal right ventricular size and function. On Day 16, a
end-organ perfusion [6]. A combination of thioamides, potassium
split-thickness skin graft was placed over her fasciotomy incision site.
iodide solution and corticosteroids are given to decrease thyroid
On Day 17 she was transferred to the ward. On Day 22, she had her
hormone production, prevent T3 and T4 release, and stop T4 to
last run of dialysis and fortunately has made a full renal recovery.
T3 conversion, respectively. Unfortunately, these processes take time
On Day 24, she provided her signed consent to allow us to write
and do not have immediate effect. Thus, the immediate management
this case report. On Day 36, she was discharged from hospital to a
is mostly symptom control and supportive care.
rehabilitation centre.
Beta-blockers are preferentially used to treat tachyarrhythmias.
Discussion The 2016 Japanese Guidelines advocates to use esmolol over
Thyroid hormones have both direct and indirect effects on the propranolol as it is short-acting and cardioselective [5]. However,
cardiovascular system. Thyrotoxicosis-induced cardiomyopathy beta blockade becomes difficult to tolerate once the patient develops
(TCM) has been previously described as a high output cardiac decompensated heart failure. Uncontrolled tachyarrhythmias in
J Clin Anesth Intensive Care 2021; 2(1): 26-30.
28Citation: Chao J, Cook R, Dhingra V. Escaping a storm alive: A case report of a young woman’s acute presentation of thyroid storm leading to cardiac arrest
salvaged by VA-ECMO. J Clin Anesth Intensive Care. 2021; 2(1): 26-30.
Antithyroid therapy
Thyrotoxicosis
Increased
sympathetic activity Excess thyroid
Direct myocyte toxicity
hormones
RAAS activation
Decreased afterload Increased heart rate
Increased preload Atrial Fibrillation
Myocardial ischemia Dilated cardiomyopathy Beta blockers
Calcium channel
blockers
Diastolic dysfunction Systolic dysfunction
Ionotropic agents
Decompensated heart failure – e.g. milrinone,
dobutamine,
Mechanical ventilation epinephrine, etc.
ECMO
Figure 3: Flow diagram depicting the potential mechanisms of thyrotoxicosis-induced cardiomyopathy and subsequent decompensated heart
failure and the management options. RAAS: Renin-Angiotensin-Aldosterone System; Orange box denotes management options; Blue arrows denote
worsening effect; Orange arrows denote improving effect.
the setting of cardiogenic shock can quickly spiral into circulatory the last decade, ECMO has been used for metabolic indications such
collapse and cardiac arrest. Ionotropic agents like dobutamine, as thyroid storm [10-13]. The intent of ECMO in thyroid storm
milrinone or epinephrine can further precipitate tachyarrhythmias, functions as a bridge towards recovery. In a recent case review by
while anti-arrhythmics like beta-blockers and calcium channel White et al. in 2018, there were 14 case reports of the use of ECMO
blockers have negative ionotropic effects that can worsen cardiac in management of thyroid storm. The survival to discharge rate was
output. Other agents such as digoxin can also be used but may not be 78.5% (10/14) with 9 of the 10 survivors able to have a cardiac
as effective in lowering HR by increasing vagal tone in patients with recovery with a LVEF of at least 50%. One patient had a presenting
high catecholamine driven states such as thyroid storm. This high EF ofCitation: Chao J, Cook R, Dhingra V. Escaping a storm alive: A case report of a young woman’s acute presentation of thyroid storm leading to cardiac arrest
salvaged by VA-ECMO. J Clin Anesth Intensive Care. 2021; 2(1): 26-30.
medical therapy, patients may still deteriorate and be salvageable Taskforce Committee for the establishment of diagnostic criteria
only through means of mechanical circulatory support via ECMO. and nationwide surveys for thyroid storm [Opinion]. Endocr J.
We report a young female who made a full recovery with ECMO 2016;63(12):1025-64.
following circulatory collapse from thyroid storm. As TCM is 7. Bourcier S, Coutrot M, Kimmoun A, Sonneville R, de Montmollin
reversible, the management of refractory cardiogenic shock with E, Persichini R, et al. Thyroid Storm in the ICU: A Retrospective
ECMO as a temporizing bridge towards recovery should be strongly Multicenter Study. Critical Care Medicine. 2020 Jan;48(1):83-90.
considered.
8. Parmar MS. Thyrotoxic atrial fibrillation. MedGenMed. 2005 Jan
4;7(1):74.
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