Thyroid Storm


Background

Clinical Features

Precipitating Factors

DDx

Lab

Treatment

  1. Supportive Therapy
  2. Inhibition of thyroid hormone release with thionamides
  3. Inhibition of new thyroid hormone production (at least 1 h (60 min) after step 2)
  4. β-adrenergic receptor blockade
  5. Preventing peripheral conversion of T4 to T3 
  6. Treat precipitating event
  7. Definitive therapy
Rapid Preparation of Thyrotoxic Patients for Emergent Surgery
  Recommended Drug Dosage Mechanism of Action Continue Postoperatively?
β-Adrenergic blockade Propranolol 40–80 mg PO 3 to 4 times a day β-Adrenergic blockade; decreased T4-to-T3 conversion (high dose)
 
Yes.
or  
Esmolol 50–100 mcg/kg/min β-Adrenergic blockade Change to PO propranolol.
Thionamide Propylthiouracil 200 mg PO every 4 h Inhibition of new thyroid hormone synthesis; decreased T4-to-T3 conversion  Stop immediately after near-total thyroidectomy; continue after nonthyroidal surgery.
or
Methimazolee 20 mg PO every 4 hours Inhibition of new thyroid hormone synthesis Stop immediately after near-total thyroidectomy; continue after nonthyroidal surgery.

 
Oral cholecystographic agent

 
Iopanoic acidd 500 mg PO twice a day Decreased release of thyroid hormone; decreased T4-to-T3conversion
 
Stop immediately after surgery.
 
Corticosteroid Hydrocortisone 100 mg PO or IV every 8 hours Vasomotor stability; decreased T4-to-T3 conversion
 
Taper over first 72 h.
or 
Dexamethasone 2 mg PO or IV every 6 hours Vasomotor stability; decreased T4-to-T3 conversion
 
Taper over first 72 h.
or  
Betamethasone 0.5 mg PO every 6 hours, IM or IV Vasomotor stability; decreased T4-to-T3 conversion
 
Taper over first 72 h.


Common Adverse Side Effects from Antithyroid Drugs:

Disposition

  1. Admit to ICU
  2. Consult Endocrinology