From the Guidelines
Thyroid storm management via nasogastric tube (NGT) is crucial for patients who cannot take oral medications, and the most recent evidence supports the use of crushed methimazole or propylthiouracil (PTU) tablets, beta-blockers like propranolol, iodine solutions, and corticosteroids like hydrocortisone. For thyroid storm management via NGT, crush methimazole tablets (20-25mg every 4-6 hours) or propylthiouracil (PTU) tablets (200-400mg every 4-6 hours) and administer through the tube with adequate water flush before and after 1.
Key Considerations
- Beta-blockers such as propranolol (40-80mg every 4-6 hours) can also be crushed and given via NGT to control sympathetic symptoms, as supported by recent studies on beta-blocker treatment for high blood pressure and thyrotoxicosis 1.
- Iodine solutions (such as Lugol's solution, 5-10 drops every 6-8 hours) should be administered at least one hour after antithyroid drugs to prevent iodine utilization for thyroid hormone synthesis.
- Corticosteroids like hydrocortisone (100mg every 8 hours) may be needed and can be given intravenously.
- Ensure the NGT is properly positioned before medication administration and flush with 30ml water between different medications to prevent interactions.
Clinical Context
This approach is crucial because thyroid storm is life-threatening with mortality rates of 10-30%, and rapid control of hyperthyroidism is essential when oral intake is compromised due to altered mental status, intubation, or gastrointestinal issues. The management of thyroid storm requires a comprehensive approach, including general supportive measures, such as oxygen, antipyretics, and appropriate monitoring, as well as treatment of the underlying cause 1.
Treatment Priorities
- Restoring a euthyroid state is the primary goal of treatment, which is usually associated with a spontaneous reversion to sinus rhythm 1.
- Antiarrhythmic drugs and electrical cardioversion are generally unsuccessful while the thyrotoxic condition persists, and beta-blockers are somewhat effective in controlling the ventricular rate in this situation 1.
From the Research
Definition and Diagnosis of Thyroid Storm
- Thyroid storm is a severe manifestation of thyrotoxicosis, diagnosed by a combination of thyroid function studies and clinical signs and symptoms of end organ damage 2
- It is characterized by low to undetectable thyroid stimulating hormone (TSH) (<0.01mU/L) with elevated free thyroxine (T4) and/or triiodothyronine (T3), and positive thyroid receptor antibody (TRab) if Graves' disease is the underlying etiology 2
Clinical Manifestations and Treatment
- Thyroid storm is an acute, life-threatening endocrine emergency that occurs when there is excess circulating thyroid hormone in the bloodstream 3
- It may be precipitated by infection, surgery, pregnancy, trauma, thyroid medication changes, or iodinated contrast exposure 3
- Treatment involves bridging to a euthyroid state prior to total thyroidectomy or radioactive iodine ablation to limit surgical complications 2
- Iodine, combined with antithyroid drugs, is recommended as an initial pharmacologic treatment for thyroid storm according to some clinical guidelines 4
Management and Outcome
- Thyroid storm requiring ICU admission causes high in-ICU mortality, with multiple organ failure and early cardiogenic shock markedly impacting the prognosis 5
- The use of potassium iodide (KI) within 2 days of admission may be associated with reduced in-hospital mortality in patients with Graves' disease 4
- Treatment should be initiated promptly, targeting all steps of thyroid hormone formation, release, and action, and patients who fail medical therapy should be treated with therapeutic plasma exchange or thyroidectomy 6