Thyroid Storm Treatment
Immediately initiate multi-drug therapy with propylthiouracil (preferred) or methimazole, followed 1-2 hours later by potassium iodide, plus beta-blockers and corticosteroids, while providing aggressive supportive care—do not delay treatment for laboratory confirmation as mortality rises significantly with delays. 1, 2
Immediate Stabilization and Hospitalization
- Hospitalize all patients with thyroid storm; severe cases require ICU admission 2, 3
- Administer supplemental oxygen immediately 2
- Position patient head-up to improve respiratory function 2
- Do not delay treatment while awaiting laboratory confirmation—mortality may rise to 75% with treatment delays 2, 4
Step 1: Block Thyroid Hormone Synthesis (First Medication)
Propylthiouracil is the preferred first-line agent because it inhibits both thyroid hormone synthesis AND peripheral conversion of T4 to T3, unlike methimazole which only blocks synthesis 1, 5
- Administer propylthiouracil as the first medication 1, 2
- Alternative: Methimazole can be used if propylthiouracil is unavailable 1, 3
- Critical pitfall: If oral access is unavailable (NPO status, altered mental status), consider rectal administration via enema or suppository 6
- Monitor for agranulocytosis with thionamide use 1, 2
Step 2: Block Thyroid Hormone Release (1-2 Hours After Thionamides)
Wait 1-2 hours after starting thionamides before giving iodine 1, 2
- Administer saturated potassium iodide solution or sodium iodide 1, 3
- Critical pitfall: Never administer iodine before thionamides—this can worsen thyrotoxicosis by providing substrate for additional hormone synthesis 1, 3
Step 3: Control Adrenergic Effects with Beta-Blockers
Propranolol is the preferred beta-blocker because it blocks peripheral T4 to T3 conversion in addition to controlling cardiovascular symptoms 1
- Typical dosing: Propranolol 60-80 mg orally every 4-6 hours 1
- For hemodynamically unstable patients: Use esmolol instead due to its ultra-short half-life allowing rapid titration 1
- Alternative if beta-blockers contraindicated: Diltiazem 15-20 mg (0.25 mg/kg) IV over 2 minutes, then 5-15 mg/h maintenance 1
- FDA warning: Beta-blockers may mask signs of hyperthyroidism, and abrupt withdrawal may precipitate thyroid storm exacerbation 7
Step 4: Reduce Peripheral T4 to T3 Conversion
- Administer dexamethasone or another corticosteroid to reduce peripheral conversion of T4 to T3 and treat potential relative adrenal insufficiency 1, 2, 3
Supportive Care
- Administer antipyretics to control fever 1
- Provide aggressive hydration 1
- Identify and treat precipitating factors (infection, surgery, childbirth, trauma) 1
- Monitor for cardiac complications such as heart failure 1, 2
Monitoring Requirements
- Continuous cardiac monitoring in ICU setting for severe cases 1
- Monitor ScvO2 >70% and cardiac index 3.3-6.0 L/min/m² if using esmolol 1
- Watch for hypotension, bradycardia, and heart failure with beta-blocker use 1
- Clinical improvement should occur within 12-24 hours 4
- Close monitoring of thyroid function every 2-3 weeks after initial stabilization 1, 2
- Watch for transition to hypothyroidism, which is common after thyroid storm treatment and may require levothyroxine replacement 1, 2
Special Populations
Pregnancy
- Treatment protocol is identical to non-pregnant patients 1, 2, 3
- Monitor fetal status continuously 1, 2
- Avoid delivery during thyroid storm unless absolutely necessary 1, 2
Rescue Therapies for Refractory Cases
If medical therapy fails to produce clinical improvement within 12-24 hours, consider advanced interventions 4:
- Therapeutic plasma exchange (TPE): Removes protein-bound T3 and T4, autoantibodies, and catecholamines 8, 9
- Emergency thyroidectomy: Should be considered as definitive treatment if medical therapy fails 4