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Thyroid Storm

Gaby Schroeder


  • Diagnosis is based on recognition of exaggerated signs/symptoms of thyrotoxicosis leading to multi-organ dysfunction in the setting of precipitating event
  • Common Precipitants: Grave’s Disease, surgery, trauma, pregnancy, stress, infection, MI/PE, medication non-compliance, iodine loads
  • Use Burch-Wartofsky Point Scale (BWPS); available on MD Calc
    • >highly suggestive
    • >25-44 impending storm
    • <25 unlikely to represent storm


  • ENDOCRINE EMERGENCY - if suspected consult Endocrine ASAP
  • Therapies directed towards thyroid gland
    • PTU: Preferred, 500-1000mg loading dose, followed by 250mg q4 -6 hours (PO, rectal)
    • Methimazole: q4-6 hours, dose varies (PO, rectal, IV)
  • Therapies directed toward decreasing T4 to T3 conversion
    • Propranolol (60-80mg PO q4)
    • Hydrocortisone (300mg x1, 100mg q8) - treats high incidence of co-existing adrenal insufficiency
  • Cholestyramine 4g QID can be considered to reduce enteric recirculation
  • Refractory Storm: plasmapheresis and plasma exchange
  • Close hemodynamic monitoring, may need vasopressors (consider transfer to ICU)