Thyroid Storms Reloaded

Management of thyroid storm entails searching for and treating that precipitating factor most commonly subtherapeutic antithyroid medication or infection. Empiric use of antibiotics is not recommended, along with pharmacologic therapy with the 3 Ps and 2 Ss;

  • Propylthiouracil (PTU) or Methimazole to reduce thyroid hormone synthesis and also assist propranolol in decreasing peripheral conversion of T4 to T3; While there has been much debate in the past over the use of the antithyroids PTU and methimazole, current literature suggests PTU to be considered second-line therapy except in people who are allergic, intolerant to methimazole, or pregnant. No current literature suggests better efficacy with PTU and the increased risk for adverse events make methimazole the preferred agent in hyperthyroid states.
  • Potassium iodide (Lugol’s Solution) or Sodium Iodide to reduce hormone release.
  • Propranolol to reduce beta-adrenergic symptoms and quell peripheral conversion of T4 to T3
  • Steroids, also to decrease peripheral T4 to T3 conversion and shield from Adrenal Insufficiency
  • Supportive care – Treat Volume Loss – Even in the setting of seeming heart failure, they may need fluids as the heart failure is high-output. Temperature Regulation – Do not aggressively cool these patients; this is contraindicated because it can lead to further vasoconstriction
  • Fix Precipitating Event/Treat Infection – Look carefully, treat aggressively

Emergency Medicine Kenya Foundation