Thyroid Storm

Thyroid storm is life threatening decompensated thyrotoxicosis with multi organ dysfunction.

• Precipitants: infection, surgery, trauma, radioiodine, amiodarone, stopping antithyroid drugs, iodinated contrast, pregnancy or delivery, diabetic ketoacidosis.
• Mortality 10 to 30% even with treatment.
• Usually Graves disease; also toxic nodular goitre.

• Fever (over 38.5 C), marked tachycardia (over 140), atrial fibrillation, heart failure.
• Agitation, delirium, psychosis, seizures, coma.
• Vomiting, diarrhoea, jaundice.
• Burch Wartofsky score of 45 or more is highly suggestive; 25 to 44 is impending storm.

• Clinical diagnosis; do not delay treatment for results.
• Suppressed TSH, raised free T4 and T3 (levels may not differ from simple thyrotoxicosis).
• Glucose, electrolytes, calcium, liver tests, cultures, ECG, troponin, echocardiography.
• Identify precipitant.

Treat in ICU

• Beta blockade: propranolol 60 to 80 mg orally every 4 hours or 0.5 to 1 mg IV then 1 to 2 mg every 15 minutes; esmolol infusion 50 to 100 micrograms/kg/min if cardiac failure risk.
• Thionamide: propylthiouracil 500 to 1000 mg loading then 250 mg every 4 hours (blocks T4 to T3 conversion), or methimazole 60 to 80 mg daily.
• Iodine 1 hour after thionamide: potassium iodide 5 drops (250 mg) every 6 hours or Lugol solution 8 drops every 6 hours.
• Hydrocortisone 100 mg IV every 8 hours (or dexamethasone 2 mg every 6 hours).
• Cholestyramine 4 g every 6 hours to reduce enterohepatic recirculation.
• Supportive: cooling with paracetamol (avoid aspirin), IV fluids, glucose, thiamine, treat heart failure and infection.
• Refractory: plasmapheresis, dialysis; thyroidectomy after stabilisation.
• Definitive therapy (radioiodine or surgery) after recovery.