How do you manage thyroid storm in the Emergency Department (ED)?

From the Guidelines

Thyroid storm in the Emergency Department should be managed with a multi-drug approach, including beta-blockers, thionamides, iodine therapy, and corticosteroids, along with supportive care and early endocrinology consultation. The initial step in management includes stabilizing the patient with IV fluids, oxygen, and cardiac monitoring.

• Beta-blockers such as propranolol (60-80 mg orally every 4-6 hours or 1-2 mg IV slowly) or esmolol (50-100 mcg/kg/min IV) should be administered to control tachycardia and other sympathetic symptoms, as supported by the ACC/AHA/ESC guidelines for the management of patients with atrial fibrillation 1.
• Thionamides, specifically propylthiouracil (PTU), should be given at a loading dose of 600-1000 mg followed by 200-250 mg every 4 hours to block new thyroid hormone synthesis, as recommended in the treatment of thyroid storm 1.
• One hour after starting thionamides, iodine therapy (Lugol's solution 10 drops every 8 hours or potassium iodide 5 drops every 6 hours) should be initiated to block thyroid hormone release.
• Corticosteroids, such as hydrocortisone (100 mg IV every 8 hours), are essential to inhibit peripheral conversion of T4 to T3 and treat potential relative adrenal insufficiency. Supportive care measures, including aggressive cooling for hyperthermia, glucose administration for hypoglycemia, and treatment of any precipitating factors like infection, are crucial in managing thyroid storm. Early endocrinology consultation and ICU admission for close monitoring are also necessary for optimal patient outcomes.

From the FDA Drug Label

Propylthiouracil inhibits the conversion of thyroxine to triiodothyronine in peripheral tissues and may therefore be an effective treatment for thyroid storm. To manage thyroid storm in the Emergency Department (ED), propylthiouracil (PO) may be used as it inhibits the conversion of thyroxine to triiodothyronine in peripheral tissues, making it an effective treatment for this condition 2.

• The key point is that propylthiouracil can be used to treat thyroid storm by inhibiting this conversion process.
• Propylthiouracil is the main drug mentioned for the management of thyroid storm.

From the Research

Management of Thyroid Storm in the ED

Thyroid storm is a life-threatening condition that requires prompt recognition and treatment in the Emergency Department (ED). The management of thyroid storm involves a multidrug approach to decrease new hormone synthesis, inhibit the release of thyroid hormone, and block the peripheral effects of thyroid hormone 3.

Treatment Approach

The treatment approach for thyroid storm typically includes:

• Thionamides, such as propylthiouracil (PTU) or methimazole, to prevent further thyroid hormone synthesis 3, 4
• Iodine solution to inhibit the release of thyroid hormone 3, 5
• Beta-adrenergic receptor antagonists, such as propranolol, to block the peripheral effects of thyroid hormone 3, 5, 6
• Corticosteroids, such as hydrocortisone, to block the peripheral conversion of T4 to T3 and to treat potential adrenal insufficiency 3, 5, 7
• Supportive therapy, including intravenous fluids and oxygen, to manage symptoms and prevent complications 5, 7

Alternative Routes of Administration

In some cases, patients with thyroid storm may not be able to tolerate oral medications, and alternative routes of administration may be required. These include:

• Rectal administration of thionamides, such as PTU, in the form of an enema or suppository 4
• Intravenous administration of methimazole, although this is not currently available in the United States 4

Potential Complications

Thyroid storm can be complicated by several factors, including:

• Acute hepatitis due to treatment with PTU 7
• Pulmonary embolus, which can be mutually causative with thyroid storm 5
• Heart strain, which can be a contraindication to the use of beta blockers 5

Key Considerations

When managing thyroid storm in the ED, it is essential to:

• Recognize the condition promptly and initiate treatment quickly 3, 4, 5
• Monitor patients closely for potential complications and adjust treatment accordingly 5, 7
• Be aware of the potential interactions between medications and the risk of adverse reactions, such as liver dysfunction with PTU treatment 7