Treatment of Thyroid Storm
Thyroid storm requires immediate treatment with a combination of propylthiouracil, potassium iodide, beta-blockers, corticosteroids, and supportive care to prevent mortality. 1
First-Line Medications
1. Blocking Thyroid Hormone Synthesis
- Administer propylthiouracil (PTU) as first choice since it both inhibits thyroid hormone synthesis and blocks peripheral conversion of T4 to T3 1, 2
- Alternatively, methimazole can be used if PTU is unavailable 1
2. Blocking Thyroid Hormone Release
- Administer saturated potassium iodide solution or sodium iodide 1-2 hours AFTER starting thionamides 1
- Critical: Never give iodine before thionamides as this can worsen thyrotoxicosis 1
3. Controlling Adrenergic Effects
- Beta-blockers are essential for controlling tachycardia and other cardiovascular symptoms 1, 3
- For hemodynamically unstable patients, consider short-acting beta-blockers like esmolol instead of propranolol 1, 4
- Caution: Beta-blockers may precipitate cardiovascular collapse in patients with underlying thyrocardiac disease 4
4. Reducing Peripheral Conversion of T4 to T3
- Administer dexamethasone or another corticosteroid to reduce peripheral conversion of T4 to T3 and treat possible relative adrenal insufficiency 1
Supportive Care
- Provide oxygen therapy as needed 1
- Administer antipyretics to control fever 1, 5
- Identify and treat precipitating factors (infection, surgery, childbirth, etc.) 1, 5
- Hospitalize all patients with thyroid storm, with severe cases requiring ICU admission 6, 5
Special Considerations
Alternative Administration Routes
- When oral administration is not possible, consider:
Monitoring and Follow-up
- Close monitoring of thyroid function every 2-3 weeks after initial stabilization 6
- Watch for transition to hypothyroidism, which is common after thyroid storm treatment 6
- Monitor for hepatocellular injury with PTU use 7
Treatment Algorithm Based on Severity
- For patients with mild to moderate symptoms: beta-blockers for symptomatic relief, hydration, and supportive care 6
- For patients with severe symptoms: hospitalization is mandatory with endocrine consultation 6, 5
Potential Complications
- Propranolol may cause circulatory collapse in patients with underlying thyrocardiac disease 4
- PTU can cause hepatocellular injury requiring discontinuation 7
- Untreated thyroid storm has a mortality rate of up to 30% 8, 5
Remember that thyroid storm is a clinical diagnosis requiring urgent recognition and treatment to prevent mortality. A multidisciplinary approach involving critical care and endocrinology specialists is essential for optimal management 5.