Initial Treatment for Thyroid Storm
The immediate treatment of thyroid storm requires a combination of propylthiouracil (preferred over methimazole), potassium iodide, beta-blockers, corticosteroids, and supportive care to prevent mortality. 1, 2
Step-by-Step Management Algorithm
1. Hospitalization and Initial Stabilization
- Hospitalize all patients with thyroid storm, with severe cases requiring ICU admission 1, 2
- Administer supplemental oxygen to stabilize the patient 2
- Position patient in head-up position to improve respiratory function 2
- Do not delay treatment while awaiting laboratory confirmation, as mortality may rise significantly with treatment delays 2
2. Blocking Thyroid Hormone Synthesis (First Step)
- Administer propylthiouracil as first choice since it inhibits both thyroid hormone synthesis and peripheral conversion of T4 to T3 1, 3
- Propylthiouracil dosing: 600-1000 mg loading dose followed by 200-250 mg every 4 hours 1
- Alternatively, methimazole can be used if propylthiouracil is not available 1
3. Blocking Thyroid Hormone Release (Second Step)
- Administer saturated potassium iodide solution or sodium iodide 1-2 hours AFTER starting thionamides 1, 2
- CRUCIAL: Never administer iodine before thionamides, as this can worsen thyrotoxicosis 1, 2
4. Controlling Adrenergic Effects
- Administer beta-blockers, such as propranolol, to control tachycardia and other cardiovascular symptoms 1, 4
- In cases of hemodynamic instability, consider using short-acting beta-blockers like esmolol for careful titration 1
- Use caution with beta-blockers in patients with heart failure, as they may precipitate cardiovascular collapse 4
5. Reducing Peripheral Conversion of T4 to T3
- Administer dexamethasone or another corticosteroid (e.g., hydrocortisone 100 mg IV every 8 hours) 1, 2
- Corticosteroids reduce peripheral conversion of T4 to T3 and treat possible relative adrenal insufficiency 1
6. Supportive Treatment
- Administer antipyretics to control fever 1
- Provide aggressive fluid resuscitation if needed 5
- Identify and treat precipitating factors (infection, surgery, childbirth, etc.) 1, 5
Special Considerations
Alternative Administration Routes
- If oral administration is not possible, rectal administration of thionamides can be considered 6
- In extreme circumstances when medical treatment fails, early thyroidectomy or plasmapheresis may be considered 7, 8
Monitoring
- Increase frequency of observations for patients with suspected thyroid storm 2
- Monitor for development of agranulocytosis with thionamide use 2
- Watch for cardiac complications such as heart failure 2
- Monitor thyroid function every 2-3 weeks after initial stabilization 1
Common Pitfalls to Avoid
- Delaying treatment while awaiting laboratory confirmation 2
- Administering iodine before thionamides 1, 2
- Failing to recognize mimics including sympathomimetic overdose, substance use disorders, alcohol withdrawal, sepsis, and serotonin syndrome 5
- Overlooking the need for a multidisciplinary approach involving critical care and endocrinology specialists 5