Treatment of Thyroid Storm
Thyroid storm requires immediate treatment with a combination of propylthiouracil or methimazole, potassium iodide, beta-blockers, corticosteroids, and supportive care to prevent mortality. 1
Step 1: Block Thyroid Hormone Synthesis
- Administer propylthiouracil (PTU) as first-line therapy since it both inhibits thyroid hormone synthesis and blocks peripheral conversion of T4 to T3 2, 3
- Alternatively, methimazole can be used if propylthiouracil is unavailable 1
- PTU dosing: 600-1000 mg loading dose, followed by 200-250 mg every 4 hours 2
Step 2: Block Thyroid Hormone Release (1-2 hours after thionamides)
- Administer saturated solution of potassium iodide (SSKI) or sodium iodide 1-2 hours after starting thionamides 2
- CRITICAL: Never administer iodine before thionamides as this can worsen thyrotoxicosis 1
- Typical dosing: 5 drops of SSKI every 6 hours 2
Step 3: Control Adrenergic Effects
- Beta-blockers are essential for controlling tachycardia and other cardiovascular symptoms 2, 4
- Propranolol is commonly used: 60-80 mg orally every 4-6 hours or 1-2 mg IV slowly 4
- For hemodynamically unstable patients, consider esmolol (short-acting beta-blocker) for careful titration 2
- If beta-blockers are contraindicated (e.g., severe bronchospasm), non-dihydropyridine calcium channel blockers can be used as alternatives 1
Step 4: Reduce Peripheral Conversion of T4 to T3
- Administer dexamethasone (2 mg IV every 6 hours) or another corticosteroid 1
- This helps reduce peripheral conversion of T4 to T3 and treats possible relative adrenal insufficiency 1
Step 5: Provide Supportive Care
- Oxygen therapy as needed 2
- Aggressive fluid resuscitation and electrolyte correction 1
- Antipyretics for fever control 1
- Identify and treat precipitating factors (infection, surgery, childbirth, trauma, etc.) 1, 5
Special Considerations
Severe or Refractory Cases
- For patients not responding to conventional therapy, consider therapeutic plasma exchange (TPE) 6
- TPE works by removing cytokines, antibodies, and thyroid hormones from circulation 6
- TPE should be initiated early in cases with severe neurological symptoms 6
Pregnancy
- Treatment protocol is similar to non-pregnant patients 1
- Monitor fetal status closely 1
- Avoid delivery during thyroid storm unless absolutely necessary 1
Monitoring and Follow-up
- Close cardiac monitoring for arrhythmias and heart failure 1
- Monitor for agranulocytosis with thionamide use 1
- Check thyroid function every 2-3 weeks after initial stabilization 2
- Watch for transition to hypothyroidism, which is common after thyroid storm treatment 2
Common Pitfalls and Caveats
- Do not delay treatment while waiting for laboratory confirmation 1
- Thyroid hormone levels do not differ between uncomplicated thyrotoxicosis and thyroid storm; diagnosis is clinical 5
- Mortality rate may rise to 75% if treatment is delayed 5
- Consider early thyroidectomy if medical treatment fails to produce clinical improvement within 12-24 hours 5