Key Points
- Stabilize ABCs; begin targeted evaluation without delaying life-saving therapy.
- Use system-specific risk tools to guide testing and disposition.
- Order high-yield tests first; escalate imaging when indicated.
- Start evidence-based initial therapy and reassess frequently.
Algorithm
- Primary survey and vitals; IV access and monitors.
- Focused history/physical; identify red flags and likely etiologies.
- Order system-appropriate labs and imaging (see Investigations).
- Initiate guideline-based empiric therapy (see Pharmacology).
- Reassess response; arrange consultation and definitive management.
Clinical Synopsis & Reasoning
For Thyroid Storm Management, frame the differential by acuity and pathophysiology, then align diagnostics to the leading hypotheses. Prioritize stabilization while obtaining high‑yield studies such as BMP (Electrolytes/anion gap), Ketones (if DKA) (Ketoacidosis), ABG/VBG (Acid–base status). Incorporate bedside imaging and targeted labs to define severity and identify complications; synthesize results with clinical trajectory to refine the working diagnosis and disposition needs.
Treatment Strategy & Disposition
Initiate disease‑directed therapy alongside supportive care, titrating to objective response. Pharmacologic options commonly include Insulin, Dextrose, Electrolytes (K+, Mg2+). Use validated frameworks (e.g., Drug Sequence (Abbrev.)) to guide escalation and site of care. Address precipitating factors, de‑escalate empiric therapies with data, and arrange follow‑up for monitoring and risk‑factor modification; admit patients with instability, high risk of deterioration, or needs for close monitoring.
Epidemiology / Risk Factors
- Diabetes and endocrine disorders depending on topic
Investigations
| Test | Role / Rationale | Typical Findings | Notes |
|---|---|---|---|
| BMP | Electrolytes/anion gap | Derangements | |
| Ketones (if DKA) | Ketoacidosis | Positive | |
| ABG/VBG | Acid–base status | Acidosis/alkalosis |
Drug Sequence (Abbrev.)
| Step | Example | Purpose |
|---|---|---|
| 1. Beta blocker | Propranolol or esmolol | Sympathetic control, reduce T4 to T3 conversion |
| 2. Thionamide | PTU or methimazole | Block new hormone synthesis |
| 3. Iodine (after 1 h) | Lugol solution or SSKI | Block hormone release |
| 4. Steroid | Hydrocortisone | Reduce conversion and treat relative adrenal insufficiency |
Pharmacology
| Medication | Mechanism | Onset | Role in Therapy | Limitations |
|---|---|---|---|---|
| Propranolol (IV/PO) | β-blockade; ↓T4→T3 conversion | Minutes | Adrenergic symptoms | Bradycardia |
| Propylthiouracil (PTU) | Thionamide | Hours | Block hormone synthesis and conversion | Hepatotoxicity |
| Iodine solution (SSKI) | Wolff–Chaikoff effect | Hours | Give >1 h after thionamide | Iodism |
| Hydrocortisone | Glucocorticoid | Hours | ↓T4→T3 conversion; adrenal support | Hyperglycemia |
Prognosis / Complications
- Improves with derangement correction; recurrence if triggers persist
Patient Education / Counseling
- Explain red flags and when to seek emergent care.
- Reinforce medication adherence and follow-up plan.
Notes
Use PTU if concern for thyroid storm in pregnancy early in gestation; switch to methimazole in second trimester if appropriate. Monitor for hepatic toxicity.