Thyroid storm - Revision history

Danbot: Strip excess bold

2026-03-22T09:37:23Z

Strip excess bold

Danbot: Add MedicationDose SMW annotations (8 entries: propranolol, esmolol, PTU, methimazole, potassium iodide, lithium, hydrocortisone, dexamethasone); dosing verified per ATA/AACE guidelines

2026-03-20T16:20:18Z

Add MedicationDose SMW annotations (8 entries: propranolol, esmolol, PTU, methimazole, potassium iodide, lithium, hydrocortisone, dexamethasone); dosing verified per ATA/AACE guidelines

@@ Line 242: / Line 242: @@
 *Admission to ICU
 ==See Also==
 *[[Hyperthyroidism]]

Cmb23: /* Block New Hormone SynthesisDoses based on American Association of Clinical Endocrinologists recommendations */

2023-10-08T20:46:05Z

Block New Hormone SynthesisDoses based on American Association of Clinical Endocrinologists recommendations

← Older revision		Revision as of 20:46, 8 October 2023
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	#'''[[PTU]]''' 500-1000mg PO or NG followed by 250mg q4hr		#'''[[PTU]]''' 500-1000mg PO or NG followed by 250mg q4hr
	#*May provide PR, but PO or NG are preferred routes (IV formulations not available in US)		#*May provide PR, but PO or NG are preferred routes (IV formulations not available in US)
			#*PTU recommended in the first trimester of pregnancy with transition to methimazole afterwards<ref>Kobaly K, Mandel SJ. Hyperthyroidism and Pregnancy. Endocrinol Metab Clin North Am. 2019 Sep;48(3):533-545. doi: 10.1016/j.ecl.2019.05.002. Epub 2019 Jun 17. PMID: 31345521.</ref>
	#*Note black box warning of hepatotoxicity so check LFTs prior		#*Note black box warning of hepatotoxicity so check LFTs prior
	#*Avoid in patients with significant liver disease; use methimazole instead		#*Avoid in patients with significant liver disease; use methimazole instead
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	#*Longer acting than PTU		#*Longer acting than PTU
	#*IV formulations may be available in Europe		#*IV formulations may be available in Europe
	#*Should be avoided in pregnancy ~~by classic teaching~~ (freely crosses placenta, birth defects)		#*Should be avoided in first trimester of pregnancy (freely crosses placenta, birth defects)<ref>Kobaly K, Mandel SJ. Hyperthyroidism and Pregnancy. Endocrinol Metab Clin North Am. 2019 Sep;48(3):533-545. doi: 10.1016/j.ecl.2019.05.002. Epub 2019 Jun 17. PMID: 31345521.</ref>
	#*Available in IV formulations outside America, but use supported by case reports only <ref>Thiessen, M. (2018). Thyroid and Adrenal Disorders. Rosen's Emergency Medicine (9th ed). Philadelphia, PA: Elsevier/Saunders.</ref>		#*Available in IV formulations outside America, but use supported by case reports only <ref>Thiessen, M. (2018). Thyroid and Adrenal Disorders. Rosen's Emergency Medicine (9th ed). Philadelphia, PA: Elsevier/Saunders.</ref>
	#'''[[Potassium iodide]] (SSKI)'''		#'''[[Potassium iodide]] (SSKI)'''

Ostermayer: /* Clinical Features */

2022-01-09T02:49:31Z

Clinical Features

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 [[File:PMC3742527 OL-06-01-0144-g00.png|thumb|Enlarged and homogeneous thyroid.]]
 [[File:PMC3371544 IJD-57-247-g002.png|thumb|"Plummer's nail" demonstrating onycholysis (separation of the nail from the nail bed). Abnormal nail findings occurs in about 5% of hyperthyroid patients.]]
-===Classic Triad===
+{{Thyrotoxicosis clinical features}}
 ===Complications===

Elcatracho: /* Background */

2021-02-09T01:55:55Z

Background

← Older revision		Revision as of 01:55, 9 February 2021
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	*Difference between severe thyrotoxicosis and thyroid storm is clinical diagnosis<ref>Nayak B1, Burman K. Thyrotoxicosis and thyroid storm. Endocrinol Metab Clin North Am. 2006 Dec;35(4):663-86, vii.</ref>		*Difference between severe thyrotoxicosis and thyroid storm is clinical diagnosis<ref>Nayak B1, Burman K. Thyrotoxicosis and thyroid storm. Endocrinol Metab Clin North Am. 2006 Dec;35(4):663-86, vii.</ref>
	**Must empirically treat before laboratory confirmation		**Must empirically treat before laboratory confirmation
	**Death caused by multi-organ dysfunction, congestive heart failure, respiratory failure, ~~disrhythmias~~, [[DIC]], hypoxic brain injury, or sepsis <ref>Thiessen, M. (2018). Thyroid and Adrenal Disorders in Rosen's emergency medicine: Concepts and clinical practice (9th ed.). Philadelphia, PA: Elsevier/Saunders.</ref>		**Death caused by multi-organ dysfunction, [[congestive heart failure]], respiratory failure, [[dysrhythmias]], [[DIC]], hypoxic brain injury, or [[sepsis]] <ref>Thiessen, M. (2018). Thyroid and Adrenal Disorders in Rosen's emergency medicine: Concepts and clinical practice (9th ed.). Philadelphia, PA: Elsevier/Saunders.</ref>

	===Precipitants===		===Precipitants===

Hirokoa33: /* Treat Increased Adrenergic Tone */

2021-01-30T16:49:10Z

Treat Increased Adrenergic Tone

← Older revision		Revision as of 16:49, 30 January 2021
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	**Relative contraindications are same as for other medical conditions (e.g. [[CHF]], [[Reactive Airway Disease]], see alternative therapies)		**Relative contraindications are same as for other medical conditions (e.g. [[CHF]], [[Reactive Airway Disease]], see alternative therapies)
	**In addition to decreasing peripheral conversion, propranolol will improve tremor, hyperpyrexia, and agitation		**In addition to decreasing peripheral conversion, propranolol will improve tremor, hyperpyrexia, and agitation
	**Unlike other beta-blockers, propranolol also partially blocks conversion of T3 ~~to T4~~		**Unlike other beta-blockers, propranolol also partially blocks conversion of T4 to T3
	:''or''		:''or''
	*[[Esmolol]] 250-500mcg/kg loading dose, then 50-100mcg/kg/min<ref>Brunette DD, Rothong C. Emergency department management of thyrotoxic crisis with esmolol. Am J Emerg Med. 1991;9(3):232-4.</ref>		*[[Esmolol]] 250-500mcg/kg loading dose, then 50-100mcg/kg/min<ref>Brunette DD, Rothong C. Emergency department management of thyrotoxic crisis with esmolol. Am J Emerg Med. 1991;9(3):232-4.</ref>
	**B1 selective so can be used with active CHF, asthma, etc		**B1 selective so can be used with active CHF, asthma, etc
	**Does not have T3 ~~to T4~~ blocking properties of propranolol		**Does not have T4 to T3 blocking properties of propranolol
	:''or''		:''or''
	*Reserpine 2.5 - 5 mg IM q4h		*Reserpine 2.5 - 5 mg IM q4h

Josgood: /* ManagementBahn chair RS, Burch HB, Cooper DS, et al. Hyperthyroidism and other causes of thyrotoxicosis: management guidelines of the American Thyroid Association and American Association of Clinical Endocrinologists. Thyroid. 2011;21(6):593-646. */

2020-11-02T19:21:14Z

ManagementBahn chair RS, Burch HB, Cooper DS, et al. Hyperthyroidism and other causes of thyrotoxicosis: management guidelines of the American Thyroid Association and American Association of Clinical Endocrinologists. Thyroid. 2011;21(6):593-646.

← Older revision		Revision as of 19:21, 2 November 2020
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	*Second most common etiology of thyroid storm (after medication noncompliance) is infection <ref>Akamizu T, et al. Diagnostic criteria, clinical features, and incidence of thyroid storm based on nationwide surveys. Thyroid 2012; 22:661. </ref>		*Second most common etiology of thyroid storm (after medication noncompliance) is infection <ref>Akamizu T, et al. Diagnostic criteria, clinical features, and incidence of thyroid storm based on nationwide surveys. Thyroid 2012; 22:661. </ref>
	*Low threshold to start broad spectrum antibiotics		*Low threshold to start broad spectrum antibiotics

			===Additional Interventions===
			*Consider L-Carnitine (1 g PO q 12h) - blocks T3 & T4 entry into cell nuclei peripherally <ref>Salvatore Benvenga, et al. Effects of carnitine on thyroid hormone action PMID: 15591013 DOI: 10.1196/annals.1320.015 </ref>
			*Consider Cholestyramine (4g PO q 6h) - decreases GI hormone recycling

	==Disposition==		==Disposition==

Beren85: /* Block New Hormone SynthesisDoses based on American Association of Clinical Endocrinologists recommendations */

2020-10-29T23:01:37Z

Block New Hormone SynthesisDoses based on American Association of Clinical Endocrinologists recommendations

← Older revision		Revision as of 23:01, 29 October 2020
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	#Lugol’s Solution 8 drops PO q 6 ''(alternative iodine source)''		#Lugol’s Solution 8 drops PO q 6 ''(alternative iodine source)''
	#Sodium Iodide 0.5mg IV Q 12 hours ''(alternative iodine source)''		#Sodium Iodide 0.5mg IV Q 12 hours ''(alternative iodine source)''
			#Cholestyramine 1-4g BID PO
			#*Inhibits enterohepatic circulation of thyroid hormone by binding to conjugated products and promote excretion

	===Adrenal Insufficiency Treatment===		===Adrenal Insufficiency Treatment===

Beren85: /* Classic Triad */

2020-10-29T22:56:46Z

Classic Triad

← Older revision		Revision as of 22:56, 29 October 2020
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	**Goitre		**Goitre
	**[[Tremor]]		**[[Tremor]]
			**Hepatomegaly
			**Jaundice

	===Complications===		===Complications===

Rossdonaldson1: /* Clinical Features */

2019-12-17T23:24:14Z

Clinical Features

← Older revision		Revision as of 23:24, 17 December 2019
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	==Clinical Features==		==Clinical Features==
	[[File:PMC5384127 TJO-47-94-g6.png\|thumb\|Bilateral infiltrative thyroid-associated exophthalmos]]		[[File:PMC5384127 TJO-47-94-g6.png\|thumb\|Bilateral infiltrative thyroid-associated exophthalmos]]
			[[File:PMC3742527 OL-06-01-0144-g00.png\|thumb\|Enlarged and homogeneous thyroid.]]
	[[File:PMC3371544 IJD-57-247-g002.png\|thumb\|"Plummer's nail" demonstrating onycholysis (separation of the nail from the nail bed). Abnormal nail findings occurs in about 5% of hyperthyroid patients.]]		[[File:PMC3371544 IJD-57-247-g002.png\|thumb\|"Plummer's nail" demonstrating onycholysis (separation of the nail from the nail bed). Abnormal nail findings occurs in about 5% of hyperthyroid patients.]]
	===Classic Triad===		===Classic Triad===

← Older revision		Revision as of 09:37, 22 March 2026
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	==Management<ref>Bahn chair RS, Burch HB, Cooper DS, et al. Hyperthyroidism and other causes of thyrotoxicosis: management guidelines of the American Thyroid Association and American Association of Clinical Endocrinologists. Thyroid. 2011;21(6):593-646.</ref>==		==Management<ref>Bahn chair RS, Burch HB, Cooper DS, et al. Hyperthyroidism and other causes of thyrotoxicosis: management guidelines of the American Thyroid Association and American Association of Clinical Endocrinologists. Thyroid. 2011;21(6):593-646.</ref>==
	''Identify precipitant (i.e. med noncompliance, [[DKA]], infection).''		''Identify precipitant (i.e. med noncompliance, [[DKA]], infection).''
	~~'''~~''When in doubt of diagnosis, the EP should treat given the high mortality rate, as a few doses of anti-thyroid medication are unlikely to harm euthyroid patient<ref>LoPresti J. A New Look at Thyroid Emergencies Part II: Handling Thyroid Storm. http://epmonthly.com/article/a-new-look-at-thyroid-emergencies-part-ii-handling-thyroid-storm/.</ref>~~'''~~''		''When in doubt of diagnosis, the EP should treat given the high mortality rate, as a few doses of anti-thyroid medication are unlikely to harm euthyroid patient<ref>LoPresti J. A New Look at Thyroid Emergencies Part II: Handling Thyroid Storm. http://epmonthly.com/article/a-new-look-at-thyroid-emergencies-part-ii-handling-thyroid-storm/.</ref>''
	===Supportive care===		===Supportive care===
	#~~'''~~[[Fever]]~~'''~~		#[[Fever]]
	#*Do not aggressively cool as this can lead to vasoconstriction<ref>Chiha, Maguy, Shanika Samarasinghe, and Adam S Kabaker. 2013. Thyroid storm: an updated review. Journal of intensive care medicine, no. 3. http://www.ncbi.nlm.nih.gov/pubmed/23920160.</ref>		#*Do not aggressively cool as this can lead to vasoconstriction<ref>Chiha, Maguy, Shanika Samarasinghe, and Adam S Kabaker. 2013. Thyroid storm: an updated review. Journal of intensive care medicine, no. 3. http://www.ncbi.nlm.nih.gov/pubmed/23920160.</ref>
	#*Careful cooling measures (ice packs & cooling blankets)		#*Careful cooling measures (ice packs & cooling blankets)
	#*[[Acetaminophen]] (~~'''~~avoid aspirin or NSAIDS~~'''~~ because they displace thyroid hormone from TBG)		#*[[Acetaminophen]] (avoid aspirin or NSAIDS because they displace thyroid hormone from TBG)
	#~~'''~~[[Dehydration]]/[[hypoglycemia]]~~'''~~		#[[Dehydration]]/[[hypoglycemia]]
	#*D5NS (most patients have depleted glycogen stores)		#*D5NS (most patients have depleted glycogen stores)
	#*Crackles in lungs are likely [[high output heart failure]], NOT fluid overload		#*Crackles in lungs are likely [[high output heart failure]], NOT fluid overload
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	===Block New Hormone Synthesis<ref>Doses based on American Association of Clinical Endocrinologists recommendations</ref>===		===Block New Hormone Synthesis<ref>Doses based on American Association of Clinical Endocrinologists recommendations</ref>===
	''Thionamides are the main class of medications which prevent new hormone synthesis by inhibiting the iodination of tyrosine residues by thyroid peroxidase (TPO) enzymes. Propylthiouracil (PTU) is prefered over methimazole because it will also bock T4→T3 conversion''		''Thionamides are the main class of medications which prevent new hormone synthesis by inhibiting the iodination of tyrosine residues by thyroid peroxidase (TPO) enzymes. Propylthiouracil (PTU) is prefered over methimazole because it will also bock T4→T3 conversion''
	#~~'''~~[[PTU]]~~'''~~ 500-1000mg PO or NG followed by 250mg q4hr		#[[PTU]] 500-1000mg PO or NG followed by 250mg q4hr
	#*May provide PR, but PO or NG are preferred routes (IV formulations not available in US)		#*May provide PR, but PO or NG are preferred routes (IV formulations not available in US)
	#*PTU recommended in the first trimester of pregnancy with transition to methimazole afterwards<ref>Kobaly K, Mandel SJ. Hyperthyroidism and Pregnancy. Endocrinol Metab Clin North Am. 2019 Sep;48(3):533-545. doi: 10.1016/j.ecl.2019.05.002. Epub 2019 Jun 17. PMID: 31345521.</ref>		#*PTU recommended in the first trimester of pregnancy with transition to methimazole afterwards<ref>Kobaly K, Mandel SJ. Hyperthyroidism and Pregnancy. Endocrinol Metab Clin North Am. 2019 Sep;48(3):533-545. doi: 10.1016/j.ecl.2019.05.002. Epub 2019 Jun 17. PMID: 31345521.</ref>
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	#**PTU has earlier onset of action and capacity to inhibit peripheral conversion of T4 to T3		#**PTU has earlier onset of action and capacity to inhibit peripheral conversion of T4 to T3
	#**However, no significant difference in mortality between PTU and methimazole<ref>Isozaki O et al. Treatment and management of thyroid storm: analysis of the nationwide surveys: The taskforce committee of the Japan Thyroid Association and Japan Endocrine Society for the establishment of diagnostic criteria and nationwide surveys for thyroid storm. Clin Endocrinol (Oxf). 2016; 84(6):912-8 (ISSN: 1365-2265).</ref>		#**However, no significant difference in mortality between PTU and methimazole<ref>Isozaki O et al. Treatment and management of thyroid storm: analysis of the nationwide surveys: The taskforce committee of the Japan Thyroid Association and Japan Endocrine Society for the establishment of diagnostic criteria and nationwide surveys for thyroid storm. Clin Endocrinol (Oxf). 2016; 84(6):912-8 (ISSN: 1365-2265).</ref>
	#~~'''~~[[Methimazole]]~~'''~~ 20-25mg q4hr (80 - 100 mg daily in divided doses)		#[[Methimazole]] 20-25mg q4hr (80 - 100 mg daily in divided doses)
	#*Longer acting than PTU		#*Longer acting than PTU
	#*IV formulations may be available in Europe		#*IV formulations may be available in Europe
	#*Should be avoided in first trimester of pregnancy (freely crosses placenta, birth defects)<ref>Kobaly K, Mandel SJ. Hyperthyroidism and Pregnancy. Endocrinol Metab Clin North Am. 2019 Sep;48(3):533-545. doi: 10.1016/j.ecl.2019.05.002. Epub 2019 Jun 17. PMID: 31345521.</ref>		#*Should be avoided in first trimester of pregnancy (freely crosses placenta, birth defects)<ref>Kobaly K, Mandel SJ. Hyperthyroidism and Pregnancy. Endocrinol Metab Clin North Am. 2019 Sep;48(3):533-545. doi: 10.1016/j.ecl.2019.05.002. Epub 2019 Jun 17. PMID: 31345521.</ref>
	#*Available in IV formulations outside America, but use supported by case reports only <ref>Thiessen, M. (2018). Thyroid and Adrenal Disorders. Rosen's Emergency Medicine (9th ed). Philadelphia, PA: Elsevier/Saunders.</ref>		#*Available in IV formulations outside America, but use supported by case reports only <ref>Thiessen, M. (2018). Thyroid and Adrenal Disorders. Rosen's Emergency Medicine (9th ed). Philadelphia, PA: Elsevier/Saunders.</ref>
	#~~'''~~[[Potassium iodide]] (SSKI)~~'''~~		#[[Potassium iodide]] (SSKI)
	#*Give 1hr after PTU or methimazole to prevent increased hormone production (Jod-Basedow effect)<ref name="chiha">Chiha M. et al Thyroid storm: an updated review. J Intensive Care Med. 2015 Mar;30(3):131-40. </ref>		#*Give 1hr after PTU or methimazole to prevent increased hormone production (Jod-Basedow effect)<ref name="chiha">Chiha M. et al Thyroid storm: an updated review. J Intensive Care Med. 2015 Mar;30(3):131-40. </ref>
	#*Block hormone release: (Wolff-Chaikoff effect) only after hormone synthesis is inhibited. Iodine concentration leads to transient decrease of T3/T4		#*Block hormone release: (Wolff-Chaikoff effect) only after hormone synthesis is inhibited. Iodine concentration leads to transient decrease of T3/T4
	#*5 drops (0.25 mL or 250mg) orally every 6 hours		#*5 drops (0.25 mL or 250mg) orally every 6 hours
	#*Avoid potassium iodide if patient is on amiodarone		#*Avoid potassium iodide if patient is on amiodarone
	#*Can substitute radiocontrast dyes (Iopanoic acid, ipodate and iopanoate), PO Lugol solution, ~~'''~~OR~~'''~~ IV sodium iodide <ref>Weingart, Scott. EMCRIT Thyroid Storm Show Notes. http://emcrit.org/podcasts/thyroid-storm/ </ref>		#*Can substitute radiocontrast dyes (Iopanoic acid, ipodate and iopanoate), PO Lugol solution, OR IV sodium iodide <ref>Weingart, Scott. EMCRIT Thyroid Storm Show Notes. http://emcrit.org/podcasts/thyroid-storm/ </ref>
	#[[Lithium]] carbonate<ref>Carroll R, Matfin G. Endocrine and metabolic emergencies: thyroid storm. Ther Adv Endocrinol Metab. 2010 Jun; 1(3): 139–145. [http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3475282/ Full Text]</ref>		#[[Lithium]] carbonate<ref>Carroll R, Matfin G. Endocrine and metabolic emergencies: thyroid storm. Ther Adv Endocrinol Metab. 2010 Jun; 1(3): 139–145. [http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3475282/ Full Text]</ref>
	#*Consider if iodine allergic		#*Consider if iodine allergic
	#*~~'''~~Lithium carbonate~~'''~~ 300mg PO q8hr		#*Lithium carbonate 300mg PO q8hr
	#*Lithium inhibits thyroid hormone release from the gland and reduces iodination of tyrosine residues, but its use is complicated by the toxicity that can ensue		#*Lithium inhibits thyroid hormone release from the gland and reduces iodination of tyrosine residues, but its use is complicated by the toxicity that can ensue
	#*Treatment of choice for iodine-induced hyperthyroidism as the result of contrast load or amiodarone		#*Treatment of choice for iodine-induced hyperthyroidism as the result of contrast load or amiodarone
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	===Adrenal Insufficiency Treatment===		===Adrenal Insufficiency Treatment===
	''Often there may be associated [[adrenal insufficiency]] (also blocks T4>T3)''		''Often there may be associated [[adrenal insufficiency]] (also blocks T4>T3)''
	*[[Hydrocortisone]] 300mg IV bolus, followed by 100mg TID for several days ~~'''~~OR~~'''~~		*[[Hydrocortisone]] 300mg IV bolus, followed by 100mg TID for several days OR
	*[[Dexamethasone]] 4mg IV q6hr		*[[Dexamethasone]] 4mg IV q6hr
	*Note that corticosteroids also inhibit conversion of T4 to T3 and block release of hormone from thyroid gland		*Note that corticosteroids also inhibit conversion of T4 to T3 and block release of hormone from thyroid gland