Thyroid Storm

Thyroid storm is a life-threatening hypermetabolic state arising from severe thyrotoxicosis and characterized by acute dysfunction of one or more organ systems. Common high-risk findings are hyperthermia, tachyarrhythmia, heart failure or pulmonary edema, CNS disturbance, and gastrointestinal or hepatic dysfunction. Graves disease is the most frequent underlying cause, but toxic nodular disease, amiodarone-induced thyrotoxicosis, thyroiditis, exogenous hormone exposure, and rare hCG-mediated or malignant etiologies can precipitate crisis.Oxford AcademicOxford AcademicApproach to the patient with thyroid storm

Obtain TSH, free T4, and T3, but do not use hormone magnitude to determine severity or defer treatment. Severe illness may reduce T4-to-T3 conversion, producing a relatively modest or even reference-range T3 despite thyroid storm. Assess end-organ injury and precipitants with ECG, chest imaging when cardiopulmonary involvement is suspected, CBC, metabolic panel, hepatic tests, glucose, lactate, and directed infectious or ischemic evaluation.Oxford AcademicOxford AcademicApproach to the patient with thyroid storm

Admit to an ICU for continuous cardiac and respiratory monitoring. Mortality estimates vary by case definition and population; reported overall mortality is approximately 5% to 12%, rising to 30% in older adults and those with comorbidity. Cardiogenic shock, multiorgan failure, respiratory failure, arrhythmias, and sepsis are major proximate causes of death.Oxford AcademicOxford AcademicApproach to the patient with thyroid storm

Initial supportive care includes oxygen and ventilatory support as needed, cautious fluid and electrolyte replacement, cooling, acetaminophen, glucose surveillance, and treatment of the precipitating condition. Correct clinically important electrolyte and acid-base disorders and monitor for hypoglycemia, particularly in critically ill patients.Oxford AcademicOxford AcademicApproach to the patient with thyroid storm

For hyperthyroidism caused by increased hormone synthesis, give a thionamide promptly, followed by iodine after at least 1 hour, glucocorticoid therapy, and appropriately selected rate control. Iodine is not a substitute for thionamide therapy in patients with autonomous nodular disease because it can increase substrate for new hormone synthesis.Oxford AcademicOxford AcademicApproach to the patient with thyroid storm

Therapy should be tailored to etiology. Thionamides do not block release of preformed hormone in destructive thyroiditis or exogenous thyroid hormone ingestion; management in these settings emphasizes supportive care, beta-blockade when appropriate, glucocorticoids in selected settings, and treatment of the specific cause.Oxford AcademicOxford AcademicApproach to the patient with thyroid storm

Consider therapeutic plasma exchange when conventional therapy fails, when thionamides are contraindicated by severe adverse reactions or liver failure, or when rapid preoperative stabilization is required. Plasma exchange transiently lowers circulating thyroid hormones and cytokines; it is a bridge rather than definitive therapy.JAMA+1JAMAThyroid Storm Treatment With Blood Exchange and ...Oxford AcademicApproach to the patient with thyroid storm

Emergency thyroidectomy is generally deferred until medical stabilization because operative risk is substantial in uncontrolled thyrotoxicosis. It remains a rare option for refractory storm, severe antithyroid-drug intolerance, or urgent need for definitive hormone control after multidisciplinary assessment.Oxford AcademicOxford AcademicApproach to the patient with thyroid storm

After recovery, continue antithyroid therapy and arrange definitive treatment planning, typically radioactive iodine or thyroidectomy, to reduce recurrent crisis risk. The appropriate modality depends on the underlying cause and patient factors; long-term management is outside the acute stabilization phase.Oxford AcademicOxford AcademicApproach to the patient with thyroid storm

Thyroid storm in pregnancy is rare but carries substantial maternal-fetal risk. Manage in an ICU with continuous cardiac and fetal monitoring and maternal-fetal medicine involvement. Diagnostic scoring systems have not been validated in pregnancy. PTU is preferred for acute storm treatment because of T4-to-T3 conversion inhibition; after stabilization, PTU is generally continued in the first trimester and methimazole is preferred later in pregnancy because of PTU hepatotoxicity and methimazole embryopathy considerations.PubMedPubMedThyroid storm in pregnancy: a review

In pregnancy, esmolol is favored when beta-blockade is required in a potentially unstable patient because of its short half-life. Propranolol can be used if cardiac dysfunction is considered unlikely, but beta-blockers require caution because pregnant patients may be particularly vulnerable to heart failure and cardiogenic shock. Avoid atenolol because of fetal growth restriction concerns.PubMedPubMedThyroid storm in pregnancy: a review

Children with thyrotoxicosis should be managed with pediatric endocrinology involvement. Thyroid storm remains a clinical diagnosis; adult scoring systems are not validated in children. Propylthiouracil is generally avoided in children outside exceptional circumstances because of fulminant hepatic failure risk.BMJBMJNotes for the general paediatrician: managing thyrotoxicosis in children and young people | BMJ Paediatrics Open