Key Points
- Use the highest‑yield diagnostic test early; do not let testing delay time‑critical therapy.
- Set objective targets and reassess frequently.
- Plan definitive source control or disease‑specific therapy when indicated; document follow‑up and patient education.
Algorithm
- Start β-blocker; load PTU (or methimazole); 1 hour later administer iodine.
- Add hydrocortisone; begin active cooling and volume/electrolyte management.
- Treat precipitants (antibiotics, ACS care, stop iodine sources); ICU monitoring; transition to definitive therapy (RAI/surgery) once controlled.
Clinical Synopsis & Reasoning
Life-threatening hyperthyroidism precipitated by infection, surgery, or withdrawal of antithyroid drugs. Start beta-blockade, administer thionamides (PTU preferred initially), give iodine at least 1 hour later to block release, add glucocorticoids, and treat precipitants; ICU monitoring and active cooling as needed.
Treatment Strategy & Disposition
Stabilize ABCs. Initiate guideline‑concordant first‑line therapy with precise dosing and continuous monitoring. Escalate to advanced/procedural interventions based on explicit failure criteria. Define ICU, step‑down, and ward disposition triggers; involve specialty teams early.
Epidemiology / Risk Factors
- Risk varies by comorbidity and precipitants; see citations for condition‑specific data.
Investigations
| Test | Role / Rationale | Typical Findings | Notes |
|---|
| Burch-Wartofsky score or JTA criteria | Severity | Support storm diagnosis | Clinical tool |
| Thyroid panel (TSH ↓, free T4/T3 ↑) | Diagnosis | Biochemical hyperthyroidism | Do not delay therapy |
| Infection/precipitant workup | Etiology | Pneumonia, UTI, MI, iodine load | Targeted therapy |
High-Risk & Disposition Triggers
| Trigger | Why it matters | Action |
|---|
| Atrial fibrillation with RVR or heart failure | Cardiovascular collapse | ICU; esmolol if unstable; avoid in overt shock |
| Hepatic dysfunction or coagulopathy | Drug toxicity risk | Prefer methimazole over PTU; monitor LFTs/INR |
| Precipitant (infection/MI) uncontrolled | Refractory state | Aggressive source control |
| Pregnancy | Therapeutic constraints | PTU in 1st trimester; methimazole after; obstetric input |
| Agitation/psychosis/hyperthermia | Severe storm | Sedation, cooling, ICU |
Pharmacology
| Medication/Intervention | Mechanism | Onset | Role in Therapy | Limitations |
|---|
| Propranolol 60–80 mg PO q4–6h (or Esmolol infusion) | β-blocker | Minutes | Rate control and symptom relief | Avoid if decompensated HF/shock |
| Propylthiouracil 500–1000 mg load → 250 mg q4h (or Methimazole 20–40 mg q6–8h) | Thionamide | Hours | Block synthesis (PTU also blocks T4→T3) | Switch to methimazole once stable |
| Iodine (SSKI 5 drops q6h or Lugol) given ≥1 h after thionamide | Iodide | Hours | Block hormone release (Wolff-Chaikoff) | Timing critical |
| Hydrocortisone 100 mg IV q8h | Glucocorticoid | Hours | Reduce T4→T3 conversion; treat relative AI | Taper when improved |
| Cholestyramine 4 g PO q6–8h (adjunct) | Bile acid sequestrant | Hours | Increase hormone clearance | GI side effects |
Prognosis / Complications
- Outcome depends on timeliness of diagnosis and definitive therapy; monitor for complications.
Patient Education / Counseling
- Provide red‑flag education, adherence guidance, and explicit return precautions; arrange timely specialty follow‑up.
References
- American Thyroid Association guideline on thyrotoxicosis/thyroid storm — Link