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Thyroid Storm
Key considerations: Thyroid storm (mortality 10-30%), Sepsis mimicking thyroid storm
Cannot miss
- Thyroid storm (mortality 10-30%)
- Sepsis mimicking thyroid storm
Likely diagnoses
- Severe thyrotoxicosis
- Thyroid storm
- Graves disease exacerbation
Red flags
- Temperature >40°C
- Altered mental status
- Heart failure
- Seizures
Workup
- history: Known hyperthyroidism, medication compliance, recent iodine exposure, surgery, infection; exam: Fever, tachycardia, tremor, goiter, exophthalmos, AMS; labs: TSH, free T4, free T3, CBC, BMP, LFTs; imaging: CXR if heart failure suspected; bedside: Burch-Wartofsky score
Management
- immediate: PTU 500-1000mg loading then 250mg q4h (blocks T4→T3 conversion); Iodine (SSKI or Lugol) 1 hour AFTER PTU; Propranolol 60-80mg PO or 1mg IV q10min; Hydrocortisone 100mg IV q8h; general: Cooling measures for hyperthermia (avoid aspirin — displaces T4 from binding proteins); Treat precipitating cause; ICU admission
Disposition
- admit: All thyroid storm patients to ICU; discharge: Never acutely; consults: Endocrinology
Clinical pearls
- Give PTU BEFORE iodine — iodine given first can worsen thyrotoxicosis (Jod-Basedow)
- Aspirin is contraindicated — it displaces thyroid hormone from binding proteins
Source and review
- ATA Thyrotoxicosis Guidelines 2016. Last reviewed: 2024-11-01