Thyroid Storm

Background

• Diagnosis: based on recognition of exaggerated signs/symptoms of thyrotoxicosis leading to multi-organ dysfunction in the setting of precipitating event
• Common Precipitants: Grave’s Disease, Surgery, Trauma, Pregnancy, stress, Infection, MI/PE, medication non-compliance, iodine loads
• Use Burch-Wartofsky Point Scale (BWPS); available on MD Calc
  • >45 highly suggestive
  • 25-44 impending storm
  • <25 unlikely to represent storm

Management

• ENDOCRINE EMERGENCY, if suspected should get Endocrine Consult ASAP
• Therapies directed towards thyroid gland:
  • PTU: Preferred, 500-1000mg loading dose, followed by 250mg q4 -6 hours (PO, rectal)
  • Methimazole: q4-6 hours, dose varies (PO, rectal, IV)
• Therapies directed toward decreasing T4 to T3 conversion:
  • Propranolol (60-80mg PO q4)
  • Hydrocortisone (300mg x1, 100mg q8)
    • Treats high incidence of co-existing adrenal insufficiency
• Cholestyramine 4g QID can be considered to reduce enteric recirculation
• Refractory Storm: Plasmapheresis and Plasma Exchange
• Supportive care and identify precipitating factor
• Close hemodynamic monitoring, may need vasopressors (likely ICU)