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; administer thionamide; after 1–2 h give iodine; add hydrocortisone.
- Treat precipitant; aggressive supportive care (cooling, fluids, nutrition).
- Titrate therapy to clinical response; transition to maintenance and plan for definitive therapy.
Clinical Synopsis & Reasoning
Severe thyrotoxicosis with multiorgan dysfunction. Start β-blockade; give PTU 500–1000 mg load then 250 mg q4h (or Methimazole 20 mg q4–6h), followed by iodine (SSKI) 1–2 h later to block release. Add hydrocortisone 100 mg IV q8h and supportive care including cooling and fluids.
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 Japanese Thyroid Association) | Severity | Quantify likelihood | — |
| TSH/free T4/T3 (do not delay) | Diagnosis | Thyrotoxicosis pattern | — |
| Infection, MI, PE workup | Triggers | Common precipitants | Treat source |
High-Risk & Disposition Triggers
| Trigger | Why it matters | Action |
|---|
| Atrial fibrillation with instability or heart failure | High mortality | ICU; esmolol infusion |
| Hyperthermia >40°C | Multiorgan failure risk | Active cooling |
| Sepsis or precipitating surgery | Worsening trigger | Aggressive source control |
| Pregnancy | Drug selection nuance | Specialist input on thionamide choice |
| Hepatic failure | PTU risk | Prefer methimazole; monitor LFTs |
Pharmacology
| Medication/Intervention | Mechanism | Onset | Role in Therapy | Limitations |
|---|
| Propranolol 20–80 mg PO q6h (or Esmolol infusion) | β-blockade | Minutes | Symptom and rate control | Watch for HF/asthma |
| PTU 500–1000 mg load then 250 mg q4h (or Methimazole 20 mg q4–6h) | Block synthesis/5'-deiodinase (PTU) | Hours | Core therapy | Hepatotoxicity (PTU) |
| SSKI 5 drops PO q6h (or Lugol) started 1–2 h after thionamide | Iodine blockade | Hours | Inhibits release | Timing crucial |
| Hydrocortisone 100 mg IV q8h | Adrenal support/T4→T3 block | Hours | Stress dosing | — |
| Cholestyramine 4 g PO QID (adjunct) | Peripheral clearance | Days | Severe cases | — |
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
- ATA hyperthyroidism/thyroid storm guidance — Link