What is the treatment for a thyroid storm?

Thyroid Storm Treatment

Thyroid storm is a medical emergency requiring immediate multi-drug therapy without waiting for laboratory confirmation: administer thionamides first, followed by iodine 1-2 hours later, beta-blockers, corticosteroids, and aggressive supportive care. 1, 2, 3

Immediate Recognition and Stabilization

Thyroid storm presents with fever, tachycardia disproportionate to fever, altered mental status, gastrointestinal symptoms (vomiting/diarrhea), and cardiac arrhythmias. 1, 3, 4 The diagnosis is entirely clinical—do not delay treatment awaiting laboratory results, as mortality can rise to 75% with treatment delays. 1, 5

All patients require hospitalization, with severe cases needing ICU admission. 1, 2

Initial stabilization measures: 1, 3

• Administer supplemental oxygen immediately
• Position patient head-up to improve respiratory function
• Provide aggressive cooling measures for hyperthermia (avoid aspirin as it may increase free thyroid hormone)

Multi-Drug Treatment Algorithm

Step 1: Block Thyroid Hormone Synthesis (Give 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, 6 Methimazole is an acceptable alternative if PTU is unavailable, though it lacks the peripheral conversion blocking effect. 2, 3

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

Administer saturated solution of potassium iodide (SSKI) or sodium iodide only after thionamides have been started—waiting 1-2 hours is critical. 1, 2, 3

Critical pitfall: Never give iodine before thionamides, as this can paradoxically worsen thyrotoxicosis by providing substrate for new hormone synthesis. 2, 3

Step 3: Control Adrenergic Symptoms

Propranolol is the beta-blocker of choice (60-80 mg orally every 4-6 hours) because it provides dual benefit: controlling cardiovascular symptoms AND blocking peripheral T4 to T3 conversion. 2

For hemodynamically unstable patients requiring vasopressor support: 2

• Use esmolol (ultra-short acting): loading dose 500 mcg/kg IV over 1 minute, then maintenance infusion starting at 50 mcg/kg/min, titrating up to maximum 300 mcg/kg/min
• Esmolol's short half-life allows rapid titration and immediate reversal if cardiovascular collapse occurs
• Requires continuous cardiac monitoring with serial blood pressure/heart rate checks every 5-15 minutes during titration

If beta-blockers are contraindicated (severe heart failure, bronchospasm): 2, 3

• Use diltiazem 15-20 mg (0.25 mg/kg) IV over 2 minutes, then 5-15 mg/h maintenance infusion

Step 4: Reduce Peripheral T4 to T3 Conversion

Administer dexamethasone or hydrocortisone to block peripheral conversion and treat potential relative adrenal insufficiency that accompanies critical illness. 1, 2, 3

Step 5: Supportive Care

• Treat hyperthermia with cooling blankets and acetaminophen (avoid aspirin) 3, 4
• Identify and aggressively treat precipitating factors: infection, surgery, trauma, diabetic ketoacidosis, labor/delivery 1, 3, 7
• Provide IV fluids for volume resuscitation 4
• Manage agitation cautiously (avoid excessive sedation that may mask neurologic deterioration)

Monitoring Requirements

• Monitor for agranulocytosis with thionamide use (fever, sore throat, infection signs) 1, 2, 3
• 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 5
• After stabilization, monitor thyroid function every 2-3 weeks 1, 2
• Watch for transition to hypothyroidism, which commonly occurs after thyroid storm treatment and may require levothyroxine replacement 1, 2

Special Populations

Pregnancy: Treatment protocol is identical to non-pregnant patients, with additional fetal monitoring and avoidance of delivery during active thyroid storm unless absolutely necessary. 1, 2, 3 Graves' disease causes 95% of hyperthyroidism in pregnancy, and thyroid storm affects less than 1% of pregnant women with hyperthyroidism. 8

Alternative Therapies (When Standard Treatment Fails)

Consider cholestyramine, lithium carbonate, or potassium perchlorate in refractory cases. 7 Plan definitive treatment (continued medical therapy, thyroidectomy, or radioactive iodine ablation) after the acute crisis resolves. 1, 3

Key Clinical Pearls

• Laboratory values (free T4, free T3) do not distinguish thyroid storm from uncomplicated thyrotoxicosis—severely ill patients may not have the highest hormone levels 1, 5
• Overall mortality is 10-20% with appropriate treatment, but can reach 75% with delayed therapy 5
• The condition is 3-5 times more common in women and occurs predominantly in elderly patients 5
• Death, when it occurs, is typically from cardiopulmonary failure 5