BCCCP: Thyroid Emergencies Critical Care Questions

Question 1 of 10

1. Question

An 82-year-old woman is brought to the emergency department in January after being found unresponsive at home. She is intubated for a Glasgow Coma Scale of 6 and profound respiratory depression. In the ICU, she is on assist-control ventilation and continuous cardiac monitoring. Her vital signs are: temperature 34.5°C (94.1°F), heart rate 48 bpm, and blood pressure 85/50 mmHg requiring a low-dose norepinephrine infusion. Physical exam reveals periorbital puffiness and nonpitting edema of her lower extremities. Initial labs show a TSH of 150 mIU/L (reference 0.4–4.0), free T4 < 0.2 ng/dL (reference 0.8–1.8), and sodium of 125 mEq/L. Based on this patient's clinical presentation, which of the following pathophysiological mechanisms is primarily responsible for her systemic decompensation?

Profound decrease in cellular metabolic activity leading to hypothermia and bradycardia.
Exaggerated adrenergic response and increased tissue sensitivity to thyroid hormones, resulting in a hypermetabolic state.
Acute adrenal insufficiency causing severe hypotension and electrolyte imbalances.
Syndrome of inappropriate antidiuretic hormone (SIADH) secretion causing severe euvolemic hyponatremia.

Question 2 of 10

2. Question

A 65-year-old woman with heart failure with reduced ejection fraction (LVEF 30%) weighing 70 kg presents to the ICU with suspected thyroid storm. She has a fever of 39.7 °C, heart rate 160 bpm with new-onset atrial fibrillation, and altered mental status. Laboratory studies show elevated free T4 and total T3 with suppressed TSH. Her home medications include furosemide and carvedilol. Which of the following pharmacologic interventions for thyroid storm in this patient requires the MOST careful titration and monitoring?

High-dose propylthiouracil (PTU) to inhibit thyroid hormone synthesis
Intravenous propranolol for heart rate control and reduction of T4-to-T3 conversion
Dexamethasone to reduce peripheral T4-to-T3 conversion and support adrenal function
Potassium iodide to acutely block thyroid hormone release

Question 3 of 10

3. Question

A 45-year-old woman with a known history of Graves’ disease presents with fever of 40 °C, tachycardia (140 bpm), and altered mental status. Her family reports she abruptly stopped methimazole several months ago because she could not afford the co-pay and had difficulty accessing a pharmacy. Laboratory studies reveal markedly elevated free T4 and T3 levels, consistent with thyroid storm. Which social determinant of health most critically contributed to the progression of her Graves’ disease to thyroid storm?

Limited health literacy regarding the importance of consistent antithyroid therapy
High out-of-pocket medication costs and limited access to pharmacy services
Unstable housing making it difficult to store and take medications regularly
Inadequate social support network for managing long-term medications

Question 4 of 10

4. Question

A 45-year-old woman is admitted to the intensive care unit for respiratory distress requiring mechanical ventilation and refractory hypotension on norepinephrine. She has a history of unintentional weight loss, heat intolerance, and palpitations. On exam she is febrile (40.5 °C), tachycardic (160 bpm), hypotensive (85/50 mm Hg on norepinephrine), and tremulous, with hyperactive bowel sounds. Initial labs show TSH <0.01 mIU/L (0.4–4.0), free T4 7.2 ng/dL (0.8–1.8), and total T3 350 ng/dL (80–200). Which of the following is the most appropriate initial antithyroid medication?

Propylthiouracil 600 mg orally loading dose, then 200 mg every 6 hours
Methimazole 20 mg orally loading dose, then 20 mg every 8 hours
Lugol’s solution (saturated potassium iodide) 5 drops orally every 6 hours
Potassium perchlorate 300 mg orally every 8 hours

Question 5 of 10

5. Question

A 72-year-old female is admitted to the critical care unit, currently intubated and on assist-control ventilation for hypoventilation, with a central venous catheter in place for vasopressor administration. Her family reports a progressive decline in mental status, lethargy, and cold intolerance over the past week. On examination, she is hypothermic (rectal temperature 92.5°F / 33.6°C), bradycardic (heart rate 45 bpm), and hypotensive (blood pressure 80/45 mmHg) requiring a low-dose norepinephrine infusion. Initial laboratory results reveal a TSH >100 mIU/L (normal 0.4–4.0 mIU/L), free T4 <0.1 ng/dL (normal 0.8–1.8 ng/dL), sodium 125 mEq/L, and glucose 60 mg/dL. Her cortisol level is pending. Which of the following is the most appropriate initial pharmacologic management for this patient?

Initiate intravenous levothyroxine 200–400 mcg loading dose, followed by daily maintenance dosing, and intravenous hydrocortisone 100 mg every 8 hours.
Initiate oral levothyroxine 100 mcg once daily and intravenous hydrocortisone 100 mg every 8 hours.
Initiate intravenous liothyronine 25 mcg every 12 hours and intravenous hydrocortisone 100 mg every 8 hours.
Initiate intravenous levothyroxine 200 mcg loading dose and intravenous liothyronine 5 mcg every 8 hours without glucocorticoids.

Question 6 of 10

6. Question

A 45-year-old woman is admitted to the intensive care unit with suspected thyroid storm. She is intubated, mechanically ventilated, and has a nasogastric tube in place for enteral medications. She requires a norepinephrine infusion at 0.05 mcg/kg/min via a central line. Her vital signs are: temperature 40.1 °C, heart rate 145 bpm, blood pressure 90/50 mmHg, and ventilator-assisted respiratory rate 28 breaths/min. She is agitated and disoriented. Laboratory results show free T4 7.5 ng/dL (normal 0.8–1.8 ng/dL), free T3 25 pg/mL (normal 2.3–4.2 pg/mL), and TSH < 0.01 mIU/L (normal 0.4–4.0 mIU/L). Initial management of thyroid storm requires a specific sequence of therapies to inhibit hormone synthesis, block peripheral conversion, control adrenergic symptoms, and address adrenal insufficiency. Which of the following represents the most appropriate initial pharmacologic management sequence for this patient?

Administer propranolol IV, then administer propylthiouracil via NG tube (load then maintenance), then administer potassium iodide via NG tube one hour after thionamide, then administer hydrocortisone IV.
Administer propranolol IV, then administer methimazole via NG tube (load then maintenance), then administer potassium iodide via NG tube one hour after thionamide, then administer hydrocortisone IV.
Administer propylthiouracil via NG tube (load then maintenance), then administer potassium iodide via NG tube immediately, then administer propranolol IV, then administer hydrocortisone IV.
Administer methimazole via NG tube (load then maintenance), then administer propranolol IV, then administer hydrocortisone IV, then administer potassium iodide via NG tube.

Question 7 of 10

7. Question

A 48-year-old woman is admitted to the intensive care unit for acute respiratory failure. She is intubated on assist-control ventilation, and a nasogastric tube is in place. A continuous norepinephrine infusion is running via a central line to maintain mean arterial pressure. She was brought in with a 2-day history of fever (104.2°F), agitation, profuse sweating, diarrhea, and a rapid decline in mental status. On examination, she is tachycardic at 165 beats/min, her skin is warm and moist, and she is diaphoretic. Laboratory results show TSH <0.01 mIU/L (0.4–4.0), free T4 7.8 ng/dL (0.8–1.8), and total T3 350 ng/dL (80–200). Her history is significant for Graves’ disease, and she has not taken her antithyroid medications for several months. Which of the following is the most appropriate initial pharmacologic intervention?

Propylthiouracil 600 mg via nasogastric tube (single loading dose)
Saturated solution of potassium iodide (5 drops orally every 6 hours)
Methimazole 20 mg via nasogastric tube every 6 hours
Propranolol 2 mg IV every 4 hours

Question 8 of 10

8. Question

A 45-year-old, 70-kg woman is admitted to the ICU with a 48-hour history of fever, agitation, and vomiting. She is intubated and on assist-control ventilation for altered mental status and respiratory distress. She has Graves’ disease but stopped methimazole 5 days ago. On exam: T 40.1°C, HR 145 bpm (sinus), BP 90/55 mmHg (on norepinephrine), RR 28. Labs: TSH <0.01 mIU/L, free T4 5.8 ng/dL, total T3 350 ng/dL. Thyroid storm is diagnosed. Which initial treatment regimen is most appropriate?

Propylthiouracil 600 mg loading via NG tube, then 200 mg every 4 hours; one hour later give Lugol’s solution (5 drops oral every 6 hours); plus IV propranolol 1–2 mg bolus then 60 mg orally every 6 hours; plus hydrocortisone 100 mg IV every 8 hours.
Methimazole 20 mg orally every 6 hours with Lugol’s solution started concurrently (5 drops every 6 hours); plus IV propranolol and hydrocortisone.
Saturated solution of potassium iodide (SSKI) 5 drops orally every 6 hours, then propylthiouracil 600 mg loading; plus IV propranolol and hydrocortisone.
Propranolol 2 mg IV every 4 hours followed by methimazole 20 mg orally every 6 hours; no iodine or steroids included.

Question 9 of 10

9. Question

A 45-year-old, 70 kg female is admitted to the ICU with thyroid storm. She is intubated on assist-control ventilation, sedated with propofol 25 mcg/kg/min and fentanyl 1 mcg/kg/hr, and receiving norepinephrine at 0.2 mcg/kg/min for a blood pressure of 90/60 mm Hg. Her temperature is 40.1 °C, heart rate is 165 bpm with atrial fibrillation, and she is agitated with fluctuating consciousness. Labs show suppressed TSH and markedly elevated free T4 and T3. Which of the following is the most appropriate initial intervention to control her tachycardia and agitation?

Initiate an IV esmolol bolus of 0.5 mg/kg over 1 minute followed by a 50 mcg/kg/min infusion, titrated to heart rate <100 bpm.
Administer intermittent IV propranolol 1 mg boluses every 10 minutes as needed for heart rate control.
Give crushed oral propranolol 40 mg via the nasogastric tube every 4 hours.
Defer beta-blockade until antithyroid drugs have been administered for at least 24 hours.

Question 10 of 10

10. Question

A 45-year-old woman presents with hyperthermia (40.3 °C), tachycardia (heart rate 160 beats/min), and altered mental status. She has a recent history of weight loss, anxiety, and tremors. Laboratory results show TSH < 0.01 mIU/L (normal 0.4–4.0), free T4 6.5 ng/dL (normal 0.8–1.8), and total T3 450 ng/dL (normal 80–200). A Burch-Wartofsky Point Scale score of 70 confirms thyroid storm. Which of the following is the most appropriate initial antithyroid drug regimen for this patient?

Propylthiouracil 600 mg via nasogastric tube once, followed by 200 mg every 6 hours.
Methimazole 20 mg via nasogastric tube every 6 hours.
Propranolol 60 mg via nasogastric tube every 4 hours.
Saturated solution of potassium iodide 5 drops every 6 hours.

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