What is the management of thyroid storm?

Management of Thyroid Storm

Thyroid storm requires immediate, aggressive treatment with a standard regimen of thionamides, beta-blockers, iodine solutions, and corticosteroids to prevent mortality, which can be as high as 30% if untreated. 1

Diagnosis

Thyroid storm is a clinical diagnosis characterized by:

• Extreme hypermetabolic state
• Fever
• Tachycardia out of proportion to fever
• Altered mental status (nervousness, restlessness, confusion, seizures)
• Gastrointestinal symptoms (vomiting, diarrhea)
• Cardiac arrhythmias and potential heart failure
• Hepatic dysfunction

Diagnosis can be aided by using the Burch-Wartofsky score or Japanese Thyroid Association criteria 1, 2. Laboratory confirmation with serum FT3, FT4, and TSH helps confirm the diagnosis, but treatment should not be delayed awaiting results 3.

Treatment Algorithm

1. Thionamide Therapy

• Administer immediately to inhibit thyroid hormone synthesis 1
• Options:
  • Propylthiouracil (PTU): Traditionally preferred due to additional inhibition of peripheral T4 to T3 conversion
  • Methimazole: Recent evidence shows no significant difference in mortality or adverse events compared to PTU 4

2. Iodine Solution

• Administer 1 hour after thionamide to prevent iodine utilization for hormone synthesis 1
• Options:
  • Saturated solution of potassium iodide (SSKI)
  • Sodium iodide
  • Lugol's solution

3. Beta-Blockers

• Administer for symptomatic relief and to control adrenergic effects 3, 1
• Options:
  • Propranolol: First-line option
  • Atenolol: Alternative option
• Use with caution in patients with severe heart failure
• Monitor for hypoglycemia, especially in diabetic patients

4. Corticosteroids

• Administer dexamethasone to reduce T4 to T3 conversion and treat potential adrenal insufficiency 1

5. Additional Medications (as needed)

• For severe cases unresponsive to standard therapy:
  • Cholestyramine: Binds thyroid hormones in intestine
  • Consider therapeutic plasma exchange for refractory cases 5
• For specific symptoms:
  • Antipyretics for fever
  • Phenobarbital for severe agitation 3
  • Reserpine, guanethidine, or diltiazem in patients with history of severe bronchospasm 3

Supportive Care

• Oxygen therapy as needed
• Cardiac monitoring
• Fluid and electrolyte management
• Semi-upright positioning
• Treatment of the underlying trigger (e.g., infection, surgery, medication non-compliance)

Special Considerations

Pregnancy

• Evaluate fetal status with ultrasound, nonstress testing, or biophysical profile 3, 1
• Avoid delivery during thyroid storm unless medically necessary 3
• Propylthiouracil is preferred in the first trimester 1

Post-Surgical Patients

• Higher vigilance needed in patients with history of thyroid disease undergoing surgery, especially cardiac procedures 6
• Ensure euthyroid state before elective surgery

Monitoring

• Close monitoring of vital signs and mental status
• Serial thyroid function tests
• Monitor for complications of treatment:
  • Hepatotoxicity with PTU
  • Agranulocytosis with thionamides
  • Hypotension with beta-blockers

Common Pitfalls to Avoid

1. Delaying treatment while awaiting laboratory confirmation
2. Administering iodine before thionamides, which can worsen thyrotoxicosis
3. Overlooking the precipitating cause of thyroid storm
4. Failing to recognize thyroid storm in critically ill patients with nonspecific symptoms
5. Inadequate beta-blockade leading to persistent tachycardia and hemodynamic instability

Thyroid storm is a medical emergency requiring prompt recognition and aggressive treatment to reduce mortality. A multidisciplinary approach involving critical care and endocrinology specialists is essential for optimal management.