Triage di emergenza endocrino per tempesta tiroidea e coma mixedema¶

Thyroid storm (thyrotoxic crisis) and myxedema coma (decompensated hypothyroidism) represent the two opposite, life-threatening extremes of thyroid gland dysfunction. In thyroid storm, a massive surge of active thyroid hormones (\(T_3\) and \(T_4\)) drives the body's metabolic engine into hyperdrive, causing extreme fever above \(40.0^\circ\text{C}\) (\(104.0^\circ\text{F}\)), racing heart rates above \(140\text{ beats per minute}\), atrial fibrillation, high-output heart failure, agitation, delirium, and fatal cardiovascular collapse. In myxedema coma, severe prolonged depletion of thyroid hormone slows every organ system to a near-standstill, resulting in profound hypothermia (core temperature often below \(35.0^\circ\text{C}\) or \(95.0^\circ\text{F}\)), dangerously slow heart rate, shallow hypoventilation with carbon dioxide buildup, low blood sugar, generalized non-pitting swelling, and coma. Because both conditions carry hospital mortality rates of 10 to 40 percent even with intensive care, immediate recognition, targeted temperature management (active cooling for thyroid storm versus passive insulation for myxedema coma), and avoiding deadly pre-hospital mistakes like giving aspirin or applying hot heating pads are critical to survival.

Fallo adesso¶

1. Call your local emergency number immediately and state either "Suspected Thyroid Storm" or "Suspected Myxedema Coma." Dial 911 in the United States and Canada, 112 across the European Union, 999 in the United Kingdom, or see all numeri di emergenza. Explicitly report the patient's known thyroid history (Graves' disease, Hashimoto's thyroiditis, prior thyroid surgery, radioactive iodine therapy, or amiodarone/lithium use) and whether they are hyperthermic and racing or hypothermic and stuporous.
2. Determine which extreme of thyroid emergency is occurring by checking temperature, pulse, skin, and mental state.
3. Thyroid Storm (Hypermetabolic): Hot, drenched in sweat, fever \(\ge 38.5^\circ\text{C}\text{ to }41.0^\circ\text{C}\) (\(101.3^\circ\text{F}\text{ to }105.8^\circ\text{F}\)), pulse racing \(> 130\text{ to }180\text{ bpm}\) (often irregular), severe tremor, extreme agitation or delirium, vomiting, diarrhea, or yellow eyes (jaundice).
4. Myxedema Coma (Hypometabolic): Ice-cold, dry, thick pale-yellowish skin, puffy eyelids and swollen tongue, body temperature \(< 35.5^\circ\text{C}\) (\(95.9^\circ\text{F}\)), pulse slow \(< 50\text{ bpm}\), slow shallow breathing, extreme drowsiness, confusion, or coma.
5. For Suspected Thyroid Storm: Begin active external cooling immediately and NEVER give aspirin. Strip off heavy clothing, point a fan at the patient, mist their skin with cool (not freezing) water, and apply wrapped ice packs or cool wet towels to the neck, armpits, and groin. If the patient is fully awake and able to swallow, you may give acetaminophen (paracetamol) for fever, but strictly forbid aspirin, bismuth subsalicylate (Pepto-Bismol), or NSAIDs. Keep them sitting semi-upright (45 degrees) if they are breathless from heart failure.
6. For Suspected Myxedema Coma: Protect the airway in the recovery position and apply PASSIVE blanket insulation only. Because an enlarged swollen tongue (macroglossia), throat edema, and depressed brain respiratory drive rapidly cause suffocation, roll an unconscious or stuporous patient onto their side in the recovery position and monitor every breath. Wrap them in dry blankets and raise the room thermostat, never applying heating pads, electric blankets, or hot water bottles.
7. Check blood sugar or look for overlapping Adrenal Crisis (Schmidt Syndrome). In myxedema coma, severe hypoglycemia is common and co-existing acute adrenal insufficiency occurs in 5 to 10 percent of cases. Never force food or liquid into the mouth of a drowsy patient; if they have a prescribed emergency hydrocortisone injection kit for co-existing Addison's disease, administer it per the adrenal crisis guide.
8. Gather all prescription bottles, supplement containers, and recent hospital discharge papers for the paramedics. Look specifically for anti-thyroid pills (methimazole, carbimazole, propylthiouracil [PTU]), thyroid hormone pills (levothyroxine, liothyronine), heart rhythm drugs (amiodarone), psychiatric drugs (lithium), cancer immunotherapy cards, or unlabelled "weight-loss / energy" supplements containing hidden bovine/porcine thyroid extract.

Endocrine emergency triage decision tree: Thyroid Storm vs. Myxedema Coma¶

Use this clinical flowchart to rapidly classify the patient's thyroid crisis and initiate the correct life-saving pre-hospital protocol while awaiting ambulance arrival.

flowchart TD
    Start["Patient with Known or Suspected Thyroid Disorder<br/>Develops Acute Altered Mental Status + Critical Sign Collapse"] --> VitalCheck{"Assess Core Temperature, Heart Rate,<br/>Skin Moisture, and Neuromuscular State"}

    VitalCheck -->|"HOT, SWEATY, & RACING:<br/>- Fever >= 38.5 C to 41 C (101.3-105.8 F)<br/>- Tachycardia > 130-180 bpm or AFib<br/>- Agitation, delirium, tremor, vomiting/diarrhea"| StormBranch["SUSPECTED THYROID STORM<br/>(Decompensated Thyrotoxicosis)"]

    StormBranch --> StormAction["IMMEDIATE THYROID STORM PROTOCOL:<br/>1. Call 911 / 112 / 999 ('Suspected Thyroid Storm')<br/>2. ACTIVE EXTERNAL COOLING: Fans, cool wet cloths, ice packs to axilla/groin<br/>3. STRICTLY NO ASPIRIN / SALICYLATES (displaces free T3/T4)<br/>4. Sit semi-upright (45 deg) if breathless / coughing pink froth<br/>5. Quiet dim room to reduce sympathetic adrenaline surges"]

    StormAction --> StormHospital["Hospital ICU Targeted Sequence:<br/>1. Beta-blocker (Propranolol or Esmolol; avoid if severe low-EF heart failure)<br/>2. Thionamide (PTU or Methimazole) to block new hormone synthesis<br/>3. Iodine (Lugol's / SSKI) WAIT >= 1 HOUR AFTER thionamide<br/>4. IV Hydrocortisone (100 mg) to block T4-to-T3 conversion"]

    VitalCheck -->|"COLD, PUFFY, & SLOW:<br/>- Hypothermia < 35.5 C (95.9 F) & no shivering<br/>- Bradycardia < 50 bpm & slow shallow breathing<br/>- Puffy face/tongue, dry doughy skin, stupor/coma"| MyxBranch["SUSPECTED MYXEDEMA COMA<br/>(Decompensated Severe Hypothyroidism)"]

    MyxBranch --> MyxAction["IMMEDIATE MYXEDEMA COMA PROTOCOL:<br/>1. Call 911 / 112 / 999 ('Suspected Myxedema Coma')<br/>2. AIRWAY FIRST: Lateral recovery position (swollen tongue/glottis risk)<br/>3. PASSIVE REWARMING ONLY: Dry blankets & warm room<br/>   (NO heating pads/electric blankets -> prevents fatal vasodilatory shock)<br/>4. Keep Nothing by Mouth (NPO); prepare for CPR if breathing stops"]

    MyxAction --> MyxHospital["Hospital ICU Targeted Sequence:<br/>1. Mechanical ventilation for hypercapnic respiratory failure<br/>2. IV Hydrocortisone (100 mg IV FIRST, before levothyroxine)<br/>3. IV Levothyroxine (T4) +/- Liothyronine (T3) loading<br/>4. IV Dextrose for hypoglycemia & cautious correction of hyponatremia"]

Head-to-head comparison: Thyroid Storm vs. Myxedema Coma¶

Every organ system in the human body has thyroid hormone receptors. Review this clinical comparison table (based on the American Thyroid Association [ATA], Japan Thyroid Association [JTA], and European Thyroid Association [ETA] guidelines) to see how opposite hormone levels transform the body:

Part 1: Deep dive into Thyroid Storm (Thyrotoxic Crisis)¶

Why simple hyperthyroidism suddenly explodes into Thyroid Storm¶

Most patients with overactive thyroid glands (hyperthyroidism) live for months with mild weight loss, warm hands, and a slightly fast pulse without immediate danger. Thyroid storm occurs when an acute physical stress or medical trigger overwhelms the body's ability to tolerate excess hormone, causing a sudden spike in unbound (free) \(T_3\) and \(T_4\) alongside a massive upregulation of beta-adrenergic receptors on the heart and blood vessels.

Common triggers that precipitate thyroid storm include: 1. Abruptly stopping anti-thyroid medication (methimazole, carbimazole, or propylthiouracil [PTU]) due to cost, illness, or side effects. 2. Acute bacterial or viral infection (pneumonia, urinary tract infection, strep throat, COVID-19, or sepsis). 3. Massive iodine load (Jod-Basedow phenomenon): Receiving iodinated intravenous CT contrast dye, taking amiodarone (each \(200\text{ mg}\) amiodarone tablet contains \(75\text{ mg}\) of organic iodine, equal to 500 times the daily human iodine requirement), or taking kelp/seaweed supplements. 4. Non-thyroidal surgery, trauma, childbirth, or Diabetic Ketoacidosis (DKA). 5. Vigorous palpation or trauma to an enlarged goiter, or recent radioactive iodine (\(^{131}\text{I}\)) therapy. 6. Factitious thyrotoxicosis: Accidental or intentional overdose of prescription levothyroxine/liothyronine or unregulated weight-loss capsules containing desiccated animal thyroid gland.

Recognizing the Burch-Wartofsky Point Scale (BWPS) clinical criteria¶

Emergency physicians diagnose thyroid storm clinically at the bedside (without waiting hours for thyroid hormone lab results) using the Burch-Wartofsky Point Scale (BWPS) and Japan Thyroid Association (JTA) criteria. A patient has life-threatening thyroid storm when thyrotoxicosis combines with multi-organ decompensation across these four domains:

1. Thermoregulatory Failure (Fever \(\ge 38.0^\circ\text{C}\) to \(> 40.0^\circ\text{C}\) [\(100.4^\circ\text{F}\) to \(> 104.0^\circ\text{F}\)]): Unlike a normal infection where a \(39^\circ\text{C}\) fever raises the heart rate to roughly \(100\text{ to }110\text{ bpm}\), in thyroid storm the heart rate is wildly out of proportion to the fever, often racing at \(140\text{ to }190\text{ bpm}\) while sweat pours off the skin.
2. Central Nervous System Dysfunction (The single strongest diagnostic clue): Ranges from mild extreme restlessness and emotional agitation to frank delirium, psychosis, extreme confusion, seizures, or coma. If a patient has a fast heart rate and fever plus altered mental status, suspect thyroid storm immediately.
3. Gastrointestinal-Hepatic Dysfunction: Profuse watery diarrhea, severe nausea and vomiting, diffuse abdominal pain, and unexplained jaundice (yellowing of the whites of the eyes and skin) caused by congestive liver hypoxia and hepatocyte necrosis.
4. Scompenso cardiovascolare: tachicardia sinusale accelerata o rapida fibrillazione atriale (\(> 140\text{ bpm}\)) che provoca uno scarso riempimento delle camere cardiache, con conseguente edema polmonare (espettorato rosa schiumoso, incapacità di distendersi, polmoni che crepitano) e shock circolatorio improvviso.

Perché il trattamento ospedaliero della tempesta tiroidea deve seguire un rigoroso ordine temporale in 4 fasi¶

Comprendere la sequenza ospedaliera aiuta gli operatori sanitari a difendere il paziente e a capire perché i medici pongono domande specifiche durante il triage: 1. Passaggio 1: blocco dei recettori beta-adrenergici (propranololo, esmololo o landiololo): Somministrato immediatamente per via endovenosa o orale per rallentare la frequenza cardiaca accelerata al di sotto di $ 100\text{ bpm}$ e prevenire aritmie fatali. (Avvertenza critica: se il paziente presenta già una grave cardiomiopatia dilatativa a bassa frazione di eiezione, la somministrazione di un beta-bloccante a lunga durata d'azione come il propranololo può causare un arresto cardiaco improvviso; i medici di terapia intensiva utilizzano esmololo o diltiazem per via endovenosa a brevissima durata d'azione supportato da ecografia al letto del paziente.) 2. Fase 2: bloccare la sintesi di nuovi ormoni (propiltiouracile [PTU] o metimazolo): i farmaci contenenti tionamide impediscono all'enzima perossidasi tiroidea (TPO) di produrre nuovi ormoni tiroidei; PTU è spesso preferito nelle prime 24 ore perché blocca anche del 40% la conversione periferica di \(T_4\) inattivo in \(T_3\) attivo. 3. Passaggio 3: bloccare il rilascio dell'ormone preformato con iodio (soluzione di Lugol o SSKI), rigorosamente ALMENO 1 ORA DOPO il passaggio 2: Lo iodio inorganico ad alte dosi blocca la ghiandola tiroidea chiusa (l'effetto Wolff-Chaikoff). Tuttavia, se lo iodio viene somministrato PRIMA che la ghiandola tiroidea venga bloccata dal PTU o dal metimazolo, la ghiandola tiroidea utilizza lo iodio come combustibile grezzo per produrre una nuova massiccia quantità di ormone tiroideo, riversando benzina sulla tempesta tiroidea. 4. Passo 4: bloccare la conversione da \(T_4\) a \(T_3\) e proteggere le ghiandole surrenali con idrocortisone IV (\(100\text{mg}\) IV ogni 8 ore): Poiché la tempesta tiroidea brucia il cortisolo naturale del corpo più velocemente di quanto le ghiandole surrenali possano produrlo (causando una relativa insufficienza surrenalica) e poiché gli steroidi bloccano la conversione periferica di $T_4\a \(T_3\), ogni paziente con tempesta tiroidea riceve una dose di stress corticosteroidi per via endovenosa.

Tabella di riferimento clinico della scala dei punti Burch-Wartofsky (BWPS) del comodino¶

I medici d'urgenza utilizzano la scala dei punti Burch-Wartofsky per calcolare la probabilità di tempesta tiroidea al capezzale. Un punteggio totale di 45 punti o superiore indica fortemente una tempesta tiroidea attiva, da 25 a 44 punti indica una tempesta tiroidea imminente e inferiore a 25 punti rende improbabile una tempesta tiroidea:

Part 2: Deep dive into Myxedema Coma (Decompensated Hypothyroidism)¶

Despite its name, a patient in "myxedema coma" does NOT have to be completely comatose to be in mortal danger. Most patients present first with severe lethargy, confusion, disorientation, slowed speech, and hypothermia; waiting until they are completely unresponsive before calling 911 / 112 / 999 delays life-saving care.

Common triggers that push chronic hypothyroidism into Myxedema Coma¶

Myxedema coma almost always strikes an older patient (80 percent are women over age 60) with long-standing hypothyroidism (or a forgotten neck scar from a thyroid surgery decades earlier) who runs out of or stops taking their daily levothyroxine tablets and then encounters a second physiological stressor: - Winter cold exposure (or living in an unheated home during winter). - Taking sedative, opioid, or tranquilizer medications: Because a hypothyroid liver metabolizes drugs at a fraction of normal speed, a single standard tablet of an opioid painkiller (morphine, oxycodone, tramadol), benzodiazepine sleeping pill, sedative antihistamine, antidepressant, or general anesthetic can stay in the bloodstream for days and precipitate full-blown myxedema coma. - Acute infection (pneumonia, urosepsis, cellulitis, or influenza). - Medications that directly disable the thyroid gland: - Amiodarone (causes hypothyroidism in up to 15 to 20 percent of patients via iodine overload). - Lithium (concentrates inside the thyroid gland and blocks hormone release). - Cancer Immune Checkpoint Inhibitors (pembrolizumab, nivolumab, ipilimumab: cause autoimmune destruction of the thyroid and pituitary glands) and tyrosine kinase inhibitors (sunitinib).

The 5 life-threatening mechanisms of Myxedema Coma¶

1. Failure of Brain Respiratory Drive (Hypercapnic Narcosis): In myxedema coma, the brainstem respiratory center loses its sensitivity to both low oxygen (hypoxia) and high carbon dioxide (hypercapnia). Combined with weak diaphragm muscles and a swollen tongue/larynx (myxedematous macroglossia and laryngeal edema), the patient takes slow, shallow breaths, retaining \(\text{CO}_2\) until they slip into carbon dioxide coma and respiratory arrest.
2. Profound Non-Shivering Hypothermia: Without thyroid hormone to generate cellular heat (ATP thermogenesis), core body temperature plummets to \(30.0^\circ\text{C}\text{ to }35.5^\circ\text{C}\) (\(86.0^\circ\text{F}\text{ to }95.9^\circ\text{F}\)). Standard home digital thermometers often read "LO" because they cannot measure below \(34.0^\circ\text{C}\) (\(93.2^\circ\text{F}\)). In addition, if a myxedema coma patient has a violent bacterial infection like pneumonia or sepsis, they often cannot mount a fever at all, presenting with a "normal" temperature of \(36.5^\circ\text{C}\) (\(97.7^\circ\text{F}\)) that hides lethal sepsis.
3. Why Active External Heating Causes Fatal Shock: Because cardiac output is severely depressed in myxedema coma, the body survives by clamping down all peripheral skin arteries (intense alpha-adrenergic vasoconstriction). If well-meaning caregivers place a heating pad, electric blanket, or hot water bottles on the cold skin, the skin capillaries dilate abruptly. Blood pools in the skin, central blood pressure drops to zero, and the patient suffers irreversible vasodilatory shock and cardiac arrest.
4. Severe Hyponatremia (Low Blood Sodium) and Hypoglycemia: Reduced kidney water clearance and excess antidiuretic hormone (ADH) dilute blood sodium below \(115\text{ to }125\text{ mmol/L}\), causing brain swelling and seizures, while impaired gluconeogenesis causes severe hypoglycemia.
5. The Cortisol-Before-Thyroid Rule (Preventing Iatrogenic Adrenal Crisis): Up to 10 percent of patients in myxedema coma also have hidden adrenal insufficiency (either autoimmune Addison's disease [Schmidt syndrome / Polyglandular Autoimmune Syndrome Type 2] or pituitary failure). Even in patients with intact adrenal glands, their sluggish adrenal cortex cannot keep up if metabolism is suddenly restarted. Hospital Rule: Doctors must administer intravenous hydrocortisone (\(100\text{ mg}\) IV) BEFORE or simultaneously with intravenous levothyroxine (\(T_4\)); giving thyroid hormone first accelerates liver clearance of the patient's last drops of cortisol and triggers an immediate, fatal adrenal crisis.

Step-by-step first aid and pre-hospital care while waiting for EMS¶

Protocol A: Immediate care for Suspected Thyroid Storm¶

• Step 1: Position for heart and lung relief: If the patient is awake, breathless, or coughing up frothy sputum (signs of acute high-output heart failure and pulmonary edema), sit them upright at a 45- to 90-degree angle with their legs dangling down to reduce fluid return to the congested lungs. If they become dizzy/faint from low blood pressure or unconscious, place them flat or on their side in the recovery position.
• Step 2: Aggressive safe cooling: Remove blankets and excess clothes. Wipe the neck, chest, arms, and legs with lukewarm-to-cool wet washcloths and run an electric fan across the damp skin to maximize evaporative heat loss. Place cloth-wrapped ice packs in the armpits, groin, and sides of the neck.
• Step 3: Medication safety check: Never give aspirin or Pepto-Bismol. Do not give extra unprescribed doses of the patient's daily beta-blocker (such as metoprolol or propranolol) if they are already showing signs of severe heart failure, wheezing, or falling blood pressure; wait minutes for paramedics to attach an ECG monitor.
• Step 4: Protect from injury during delirium: Patients in thyroid storm can experience sudden thyrotoxic psychosis or severe agitation. Clear sharp objects away, dim room lights, turn off loud televisions, and speak calmly without physically wrestling or pinning the patient down (which spikes adrenaline and core temperature further).

Protocol B: Immediate care for Suspected Myxedema Coma¶

• Step 1: Airway protection and jaw support: Because the tongue is thick and swollen (macroglossia) and throat tissues are boggy with mucopolysaccharide fluid, lying flat on the back causes the tongue to seal off the windpipe immediately. Roll the patient gently onto their side into the recovery position and tilt the chin slightly forward to keep the airway open.
• Step 2: Passive external rewarming only: Cover the patient's torso, arms, and legs with 2 to 3 dry indoor blankets, put a warm hat on their head, and place a blanket underneath them if they are on a cold floor. Remove any hot water bottles, heating pads, or electric blankets immediately.
• Step 3: Check for neck scars and medical alert jewelry: Gently inspect the base of the front of the neck (just above the collarbone notch) for a thin horizontal thyroidectomy scar, which is often the only clue in an unconscious older adult living alone that they have no thyroid gland and are in myxedema coma.
• Step 4: Keep Nothing by Mouth (NPO): Because swallowing reflexes are paralyzed and the intestines are often in paralytic ileus, never try to force a drowsy patient in myxedema coma to swallow their missed levothyroxine pill or drink water; hospital doctors must give intravenous levothyroxine and intravenous hydrocortisone.

Script di comunicazione esatto per i servizi di emergenza sanitaria 911/112/999 e triage ospedaliero¶

Use these clear clinical scripts so dispatchers and emergency physicians recognize the endocrine crisis immediately rather than misdiagnosing it as simple sepsis, stroke, or dementia:

• For Suspected Thyroid Storm:

  "I need an emergency ambulance at [Exact Address]. The patient is a [Age]-year-old [male/female] with [Graves' disease / hyperthyroidism / a neck goiter] who has a high fever of [Temp], a racing heart rate over [140+ bpm], and acute [delirium / agitation / vomiting and diarrhea / shortness of breath]. We suspect life-threatening Thyroid Storm. We are cooling [him/her] externally and have NOT given any aspirin."

• For Suspected Myxedema Coma:

  "I need an emergency ambulance at [Exact Address]. The patient is a [Age]-year-old [male/female] with [hypothyroidism / a thyroidectomy neck scar / missed levothyroxine] who is severely confused and stuporous, ice-cold to the touch with a temperature of [Temp / 'LO'], a slow heart rate under [50 bpm], and slow shallow breathing. We suspect Myxedema Coma. We have [him/her] in the recovery position wrapped in dry blankets with no active heating pads."

Domande frequenti¶

Why can you not give aspirin to bring down the high fever during a thyroid storm?¶

In the bloodstream, over 99 percent of thyroid hormone (T4 and T3) is attached to carrier proteins where it stays inactive, leaving less than 1 percent "free" and active. Aspirin (acetylsalicylic acid) and other salicylates chemically knock thyroid hormone off those carrier proteins, instantly doubling or tripling the level of active free thyroid hormone in the blood and worsening the life-threatening thyroid storm; always use external cooling and acetaminophen (paracetamol) instead.

Why is it dangerous to put an electric heating blanket or hot water bottle on someone in myxedema coma who is freezing cold?¶

A person in myxedema coma has a very weak, slow heart and low blood volume, and their body is only keeping blood pressure up by tightly constricting all the blood vessels in their skin. Putting an electric blanket, heating pad, or hot water bottle on their skin forces those surface blood vessels to open up (vasodilate) all at once, draining blood away from the heart and brain and causing sudden, irreversible shock and cardiac arrest; always use passive rewarming with dry blankets in a warm room.

Why do hospital doctors give intravenous hydrocortisone (a steroid) before giving thyroid hormone in myxedema coma?¶

Up to 10 percent of patients with autoimmune hypothyroidism also have hidden adrenal insufficiency (Addison's disease or pituitary failure), and even patients with normal adrenal glands have sluggish cortisol production during myxedema coma. If a doctor gives intravenous thyroid hormone (levothyroxine) first, the sudden jump in metabolism burns up the body's remaining trace of cortisol within hours, triggering a fatal adrenal crisis; giving 100 milligrams of intravenous hydrocortisone first protects the patient's blood pressure and heart.

Can a common heart medication like amiodarone trigger either thyroid storm or myxedema coma?¶

Yes, amiodarone (a widely prescribed anti-arrhythmic heart medication) is 37 percent iodine by weight and releases roughly 500 times the normal daily human requirement of iodine into the bloodstream every single day. Depending on the patient's underlying thyroid gland, amiodarone can either overload the thyroid to cause severe Amiodarone-Induced Thyrotoxicosis (leading to thyroid storm) or shut down the thyroid gland to cause severe hypothyroidism and myxedema coma, even months after stopping the drug.

Fonti controllate¶

• American Thyroid Association (ATA, United States) and American Association of Clinical Endocrinology (AACE): Guidelines for Diagnosis and Management of Hyperthyroidism and Other Causes of Thyrotoxicosis (Ross et al., Thyroid) and Guidelines for the Treatment of Hypothyroidism: Prepared by the American Thyroid Association Task Force on Thyroid Hormone Replacement (Jonklaas et al., Thyroid, including myxedema coma ICU protocols).
• Japan Thyroid Association (JTA) e Japan Endocrine Society (JES): Linee guida per la gestione della tempesta tiroidea (Satoh et al., Endocrine Journal, criteri diagnostici, selezione dei beta-bloccanti e stratificazione del rischio di mortalità).
• European Thyroid Association (ETA) e Society for Endocrinology (Regno Unito): Society for Endocrinology Endocrine Emergency Guidance: Gestione dell'emergenza della tempesta tiroidea e della crisi di mixedema (ipotiroidismo scompensato) in pazienti adulti (Connessioni endocrine).
• National Institute for Health and Care Excellence (NICE, Regno Unito): Malattie della tiroide: valutazione e gestione (Linea guida NICE NG145).
• Burch HB, Wartofsky L: Tireotossicosi pericolosa per la vita: tempesta tiroidea (Endocrinology and Metabolism Clinics of North America, sistema di punteggio diagnostico fondamentale della Burch-Wartofsky Point Scale [BWPS]).

Guide correlate¶

• Crisi surrenale e iniezione d'emergenza di idrocortisone
• Pronto soccorso per ipotermia e congelamento
• Raffreddamento di emergenza per colpo di calore e esaurimento da calore
• Riconoscimento dello shock e gestione del primo soccorso
• Riconoscimento della sepsi e dello shock settico