Key Points
- Stabilize ABCs; treat life‑threatening derangements immediately.
- Confirm diagnosis early with highest‑yield imaging/labs.
- Initiate guideline‑based therapy and escalate by response.
- Plan disposition and follow‑up explicitly.
Clinical Synopsis & Reasoning
Thyroid storm is decompensated thyrotoxicosis with multisystem dysfunction. Do not delay treatment while scoring. Block adrenergic effects with esmolol infusion or propranolol (e.g., 60–80 mg PO q6h). Give a thionamide—PTU load 500–1000 mg then 250 mg q4h (or methimazole 20 mg q4–6h)—followed ≥1 hour later by iodide (e.g., SSKI 5 drops q6h or Lugol’s). Administer hydrocortisone 100 mg IV q8h, aggressive volume/temperature control, and treat precipitants.
Treatment Strategy & Disposition
Thyroid storm is decompensated thyrotoxicosis with multisystem dysfunction. Do not delay treatment while scoring. Block adrenergic effects with esmolol infusion or propranolol (e.g., 60–80 mg PO q6h). Give a thionamide—PTU load 500–1000 mg then 250 mg q4h (or methimazole 20 mg q4–6h)—followed ≥1 hour later by iodide (e.g., SSKI 5 drops q6h or Lugol’s). Administer hydrocortisone 100 mg IV q8h, aggressive volume/temperature control, and treat precipitants.
Epidemiology / Risk Factors
- Risk varies by comorbidity and precipitating factors
Initial Targets
| Parameter | Target/Action |
|---|
| Hemodynamics | Maintain perfusion; avoid hypotension |
| Monitoring | Serial exam, labs, and imaging |
| Therapy | Start early, reassess, de‑escalate when appropriate |
Investigations
| Test | Role / Rationale | Typical Findings | Notes |
|---|
| CBC | Screen leukocytosis/anemia | Context‑specific | Trend response |
| BMP | Electrolytes/renal function | Derangements common | Replace K+/Mg2+ |
| Key imaging | Condition‑specific (CTA/MRI/Endoscopy) | See text | Do not delay when red flags |
Pharmacology
| Medication | Mechanism | Onset | Role in Therapy | Limitations |
|---|
| Propranolol / Esmolol | β‑blocker | Immediate | Adrenergic control; ↓T4→T3 | Caution in decompensated HF/asthma |
| PTU / Methimazole | Thionamide | Hours | Block synthesis (PTU also ↓T4→T3) | PTU hepatotoxicity; agranulocytosis |
| SSKI / Lugol’s iodine | Iodide | Hours | Block release (after thionamide) | Give ≥1 h after thionamide |
| Hydrocortisone | Glucocorticoid | Hours | ↓T4→T3; adrenal support | Hyperglycemia, infection |
Prognosis / Complications
- Outcome depends on timeliness of diagnosis and definitive therapy
Patient Education / Counseling
- Explain red flags, adherence, and follow‑up plan
References
- Endotext: Thyroid Storm — Link
- ATA 2016 Hyperthyroidism Guideline — Link