Hyperthyroidism and Blunt Multi-System Trauma

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We report a case of multi-system trauma after a motor vehicle collision with documented hyperthyroidism. Intensive care was required including a tube thoracostomy and a tracheostomy. Elevated thyroid function tests were noted and the patient responded to anti-thyroid medication. The patient was decannulated prior to discharge to home. 48 year-old male driver was involved in a rollover motor vehicle collision with ejection. He was intubated in the field and transported to a Level 1 trauma center. At the time of admission his blood pressure was 184/132 with a pulse of 118 and a respiratory rate of 24. The initial abdominal ultrasound was negative and the pelvis was stable on exam. The chest x-ray revealed a moderate right pneumothorax with 1st and 2nd rib fractures. A right chest tube was inserted. An admission arterial blood gas revealed a PH of 7.11, PC02 of 63 and a Pa02 of 134 with a bicarbonate of 20 and a base deficit of 9. A CT survey revealed thyromegaly with surrounding blood and a spleen laceration with a blush. Intensive care unit observation ensued and no further therapy for the spleen injury was required. The patient remained hypertensive and tachycardic. Thyroid function tests were obtained. Free T4 and T3 were both elevated and TSH was very low. He appeared toxic and a presumptive diagnosis of thyrotoxicosis was made with impending thyroid storm. Methimazole was initiated along with beta-blockade (propranolol). The thyroid function tests remained elevated and he was switched to Propylthiouracil. His vital signs stabilized and he was eventually extubated. Post-extubation stridor developed and a tracheostomy was performed. He was weaned and eventually decannulated. He was discharged to home in satisfactory condition on daily anti-thyroid medication.