What is the treatment for thyroid storm?

Treatment of Thyroid Storm

Thyroid storm requires immediate multi-drug therapy without waiting for laboratory confirmation, combining propylthiouracil (preferred over methimazole), potassium iodide given 1-2 hours AFTER starting the thionamide, beta-blockers, and corticosteroids, with all severe cases requiring ICU admission. 1, 2

Immediate Hospitalization and Stabilization

• All patients with thyroid storm must be hospitalized, with severe cases requiring ICU admission 2, 3
• Provide supplemental oxygen immediately and position the patient head-up to improve respiratory function 2
• Do not delay treatment while awaiting laboratory confirmation—mortality can rise to 75% with treatment delays 2, 4

Multi-Drug Treatment Algorithm

Step 1: Block Thyroid Hormone Synthesis (Start First)

• Propylthiouracil (PTU) is the preferred first-line agent because it both inhibits thyroid hormone synthesis AND blocks peripheral conversion of T4 to T3 1, 2, 5
• Typical dosing: 600-1000 mg loading dose, then 200-250 mg every 4 hours 1
• Methimazole can be used if PTU is unavailable, but it lacks the peripheral conversion blocking effect 1
• Monitor for agranulocytosis with thionamide use 1, 2

Step 2: Block Thyroid Hormone Release (Give 1-2 Hours AFTER Thionamides)

• Administer saturated potassium iodide solution (SSKI) or sodium iodide 1-2 hours after starting thionamides 1, 2, 6
• Critical pitfall: NEVER give iodine before thionamides—this can worsen thyrotoxicosis by providing substrate for more hormone synthesis 1, 2, 6

Step 3: Control Adrenergic Symptoms with Beta-Blockers

• Propranolol is the preferred beta-blocker because it also blocks peripheral T4 to T3 conversion in addition to controlling cardiovascular symptoms 1
• Dosing: 60-80 mg orally every 4-6 hours, or IV formulation for critically ill patients 1
• For hemodynamically unstable patients, use esmolol (short-acting, easily titratable, onset within 1 hour) 1, 6
• Use beta-blockers cautiously in severe heart failure, bronchospastic disease, or peripheral vascular disease 1

Step 4: Reduce Peripheral T4 to T3 Conversion

• Administer dexamethasone or another corticosteroid to block peripheral conversion and treat potential relative adrenal insufficiency 1, 2, 6
• Corticosteroids provide dual benefit in thyroid storm management 2

Supportive Care

• Administer antipyretics for fever control (avoid aspirin as it can displace thyroid hormone from binding proteins) 1
• Provide aggressive hydration and electrolyte replacement 2
• Identify and treat precipitating factors (infection, surgery, trauma, diabetic ketoacidosis, pregnancy/childbirth) 1, 2
• Treat hyperthermia aggressively with cooling measures 3

Monitoring Requirements

• Monitor thyroid function every 2-3 weeks after initial stabilization 1, 2
• Watch for cardiac complications including heart failure and arrhythmias 1, 2
• Expect clinical improvement within 12-24 hours—if no improvement occurs, consider early thyroidectomy 4
• Watch for transition to hypothyroidism, which commonly occurs after thyroid storm treatment 1, 2

Special Populations

Pregnancy

• Treatment protocol is identical to non-pregnant patients 1, 2, 6
• Monitor fetal status continuously 2, 6
• Avoid delivery during active thyroid storm unless absolutely necessary 2, 6

Definitive Treatment Planning

• After acute crisis resolves, plan definitive treatment of underlying thyrotoxicosis (continued medical therapy, thyroidectomy, or radioactive iodine ablation) 2
• If medical treatment fails to produce clinical improvement within 12-24 hours, early thyroidectomy should be considered 4

Key Clinical Pitfall

The most critical error is administering iodine before thionamides—this sequence error can dramatically worsen thyrotoxicosis by providing substrate for accelerated hormone synthesis before blocking the synthetic machinery 1, 2, 6