There are no specific lab value parameters that differentiate thyroid storm from less severe thyrotoxicosis, but the presence of multiorgan dysfunction is key8. We have a great guideline for general thyrotoxicosis management (“Thyrotox Updated Guideline”) on the Intranet, so this Cheese is only a closer look at thyroid storm in particular.
Clinical Presentation:
-Typically affects women 20-50, those with Graves’ disease.
-Vitals and Exam: Febrile, hypertensive, and/or tachycardic, atrial fibrillation, diaphoresis, skin flushing, warmth to touch, goiter, diffuse abdominal pain, signs of heart failure
-Patients commonly present with altered mental status, anxiety, or emotional lability. GI symptoms including diarrhea and vomiting are very common8. Geratric populations may present with weakness, fatigue, confusion, and sometimes without fever, otherwise known as “apathetic thyroid storm”4.
-Think thyroid storm when you have a patient with known hyperthyroidism now acutely deteriorating, new atrial fibrillation or CHF, septic presentation without a clear source, hyperthermia, or acute psychosis/delirium with fever and tachycardia6.
Possible Triggers:
- active infection (most common)
- DKA, MI, PE
- recent contrast administration
- pregnancy
- medication non-adherence
- trauma
Diagnosis:
-Send off CBC, CMP, TSH/T4/T3, EKG, CXR, cardiac markers, other infectious work-up if it looks like that may be the cause.
If your patient has a known history of thyroid disease and presents with the above symptoms, diagnosis is more straightforward. For the undifferentiated patient that presents like this, there are the Burch-Wartofsky Scale (BWPS) and the Japanese Thyroid Association (JTA) Criteria that can aid in diagnosis. The BWPS criteria is entirely based on clinical presentation, as well as presence of a trigger3, while JTA has the prerequisite of a diagnosis of thyrotoxicosis with elevated T3/T4, LFTs in addition to clinical signs2. A 2024 comparative review of these two and the Akamizu criteria, another which combines TFTs and clinical signs, determined that basically all criteria include a highly subjective component5 - data is limited in terms of superiority between them, and so if clinical suspicion is high, go ahead and treat.
Treatment6-8:
Supportive care(IV fluids, dextrose) - consider broad-spectrum antibiotics if infection is suspected trigger7-8.
Give a thionamide! Guidelines vary in terms of whether methimazole or PTU is first line. Our thyrotoxicosis guideline highlights methimazole. Lee et. al’s 2023 multicenter cohort comparative effectiveness study concluded that there was no significant difference between the two in terms of mortality and adverse events9. PTU is still preferred in first trimester pregnancy.
Treat beta-adrenergic symptoms - Propranolol historically is the preferred agent as it also blocks peripheral conversion of T4 to T3 (preferred in pregnant individuals as well). However, if myocardial dysfunction is present (POCUS!), beta-blockade, especially with a long-acting agent may tip your patient into cardiogenic shock. A 2023 systematic review found long-acting beta-blockers like propranolol were more likely to result in circulatory collapse in thyroid storm patients1. All that to say, esmolol is your safest bet. It’s easier to titrate, and you can avoid unnecessarily aggressive beta-blockade.
Give a corticosteroid (usually hydrocortisone) to prevent peripheral conversion of T4 to T3.
Give iodine at least 1 hour after thionamide administration to prevent thyroid hormone release.
Give cholestyramine to inhibit enterohepatic thyroid hormone circulation.
Run it back! Make sure the inciting cause has been appropriately addressed → admit to MICU for close monitoring and further management.
Key Points:
If you suspect thyroid storm, treat early! There are no strict defining symptoms or lab values. Make sure you try to address the trigger alongside management. Beta blockade is important, but timely thionamide administration is more crucial, so start with this - especially if you’re worried about cardiac dysfunction. Always do a bedside echo in addition to your usual EKG, CXR, trop/bnp before giving beta-blockers!
Special note:
Anticipate a difficult airway if your patient has a large goiter. Try a smaller ETT +/- bougie or a supraglottic airway. Avoid surgical airways if possible due to thyroid bleeding risk8.
Authored by Dr. Nanditha Ravichandran, Dr. Joanne Routsolias, and Dr. Eric Leser