Back to Basics: Thyroid Storm

Thyroid Storm


  • Precipitating factors: Untreated primary hyperthyroidism (i.e. Grave’s), thyroid surgery, trauma, infection, iodine exposure, amiodarone
  • 10-30% mortality


  • Vitals - High fever (104F), tachycardia
  • Cardiac - palpitations, DOE, wide pulse pressure, ischemia, afib, heart failure symptoms
  • CNS - agitation, delirium, confusion, coma
  • GI - nausea, vomiting, diarrhea
  • Liver - hepatomegaly, dysfunction/failure, jaundice

Diagnosis is clinical - Burch and Wartofsky scoring system can help

Labs: can see elevated T4 and T3, low TSH, leukocytosis, elevated BUN, elevated transaminases, hypercalcemia, hyperglycemia


Thionamides - blocks new thyroid hormone synthesis, inhibits thyroid peroxidase

  • Propylthiouracil (PTU) also decreases peripheral conversion T4 to T3
    • 500-1000mg load then 250mg q4h PO
    • 400-600mg q6h Rectal
  • Methimazole
    • 60-120mg per daily in 4-6 doses PO
    • 20-40mg q6-8h Rectal
    • 10-30mg q6-8h IV

Beta Blocker - nonselective beta-adrenergic antagonist and decrease peripheral conversion of T4 to T3

  • Propranolol
    • 60-120mg q6h PO
    • 0.5-1mg bolus then 1-2mg q15min IV

WAIT 1 HOUR after Thionamides for Iodine (prevent iodine as substrate for new hormone)

Iodine - decrease new hormone synthesis (inhibits iodide binding to thyroglobulin in gland when iodide reach threshold), block release of preformed hormone (inhibits release of T3 and T4 from thyroglobulin)

  • SSKI
    • 5 drops q6h PO (bad tasting)
    • 250-500mg q8h Rectal
  • Lugol’s solution
    • 8 drops q6h PO
    • 5-10 drops q6-8h Rectal
  • Lithium (if iodine anaphylaxis) - inhibit T4 and T3 synthesis
    • 300mg q6-8h PO (monitor serum levels 0.6-1 mEq/L)

Glucocorticoids - prevent adrenal insufficiency and decrease T4 to T3 peripheral conversion

  • 300mg load then 100mg q8h IV

Cholestyramine - inhibits enterohepatic circulation of thyroid hormone by binding to conjugated products and promote excretion

  • 1-4g BID PO

AVOID salicylates - can increase free hormone levels (decreases T4 binding to binding globulin)



Chiha M, Samarasinghe S, Kabaker AS. Thyroid Storm: An Updated Review. Journal of Intensive Care Medicine. 2015;30(3): 131-140.