Thyroid Storm

11 Apr

-Usual etiology is in a patient with known hyperthyroidism with new physiologic stressor including infection, labor, surgery, uncontrolled DM, and trauma



-Can present in acute heart failure, fever, tachycardia, and occasionally with arrhythmias



  • Shortness of breath,
  • palpitations,
  • chest pain,
  • lower extremity edema,
  • fevers,
  • weight loss



 -Serum TSH is usually undetectable with extremely elevated levels of Free T4

Four Key Principles of Management

 1. Block Peripheral effects

Propranolol is drug of choice

Non-selective beta blocker

Also inhibits conversion T4 to T3 peripherally


2. Decrease new synthesis of thyroid hormone

Propylthiouracil (PTU) is drug of choice

Peripheral effects: Inhibits enzyme 5′-deiodinase which converts T4 to T3

Central effects: Inhibits the enzyme thyroperoxidase, an enzyme that is essential for T4 production



Same mechanism centrally as PTU but lacks peripheral effect



 3. Block Thyroid Hormone Release

In large doses, iodine actually inhibits the release of thyroid hormone

MUST be given greater than an hour after PTU, otherwise it can increase hormone synthesis


4. Supportive care including Oxygen, fever control, and Steroids

Steroids given because thought is that patients are relatively hypoadrenal because of high metabolism

Dexamethasone is also believed to slow conversion of T4 to T3


Submitted by J. Grover.


References: thyroid storm; Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 7th Edition; picture 


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