Thyroid Storm

Ben French

Overview

  • Exaggerated signs/symptoms of thyrotoxicosis causing multi-organ dysfunction in the presence of a precipitating insult.
  • Common precipitants: amiodarone, Graves’ disease, surgery (especially thyroid surgery), pregnancy, infection, MI, PE, medication non-compliance, iodine loads
  • Common presenting symptoms: tachycardia/arrythmia, new CHF, AMS, hyperthermia, diaphoresis, GI upset, new jaundice
  • If concerned for thyroid storm, use the Burch-Wartofsky Point Scale (BWPS), available on MDCalc
    • >45 is highly suggestive
    • 25-44 impending thyroid storm
    • <25 unlikely to represent thyroid storm
  • NOTE: the degree of free thyroid hormone elevation has not been shown to correlate with the incidence of thyroid storm

Management

  • ENDOCRINE EMERGENCY – ASAP consult to Endocrinology
  • Treatment of underlying precipitant
  • Supportive care including cooling blankets, vasopressors, and intubation if indicated
    • Decrease T4 to T3 conversion (give both medications):
      • PO propranolol 60-80mg every 4 hours (use cautiously in acute CHF, avoid in shock)
      • IV hydrocortisone 300mg load, followed by 100mg every 8 hours
    • Block thyroid hormone synthesis and secretion (PTU or MMI, plus Lugol’s):
      • PTU: 500-1000mg loading dose, followed by 250mg every 4 hours (PO, rectal)
      • Methimazole: 20mg every 4-6 hours (PO, rectal, IV)
  • Lugol’s solution 8 drops (0.4ml) every 6 hours, starting at least one hour after initiation of PTU or methimazole. (Lugol’s is an iodine-containing solution. Iodine suppresses thyroid hormone release via the Wolff-Chaikoff effect.)
  • Refractory storm: plasmapheresis and plasma exchange 

After recovery, patients should be recommended for definitive treatment with radioactive iodine therapy or thyroidectomy.

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