[H] How should thyroid storm be managed?

• RECOMMENDATION 30
  A multimodality treatment approach to patients with thyroid storm should be used, including beta-adrenergic blockade, antithyroid drug therapy, inorganic iodide, corticosteroid therapy, aggressive cooling with acetaminophen and cooling blankets, volume resuscitation, respiratory support and monitoring in an intensive care unit. 1/+00

Life-threatening thyrotoxicosis or thyroid storm is a rare, occasionally iatrogenic disorder characterized by multisystem involvement and a high mortality rate if not immediately recognized and treated aggressively (20). A high index of suspicion for thyroid storm should be maintained in patients with thyrotoxicosis associated with any evidence of systemic decompensation. Precise criteria for thyroid storm have been defined (Table 5) (21) and include tachycardia, arrhythmias, congestive heart failure, hypotension, hyperpyrexia, agitation, delirium, psychosis, stupor and coma, as well as nausea, vomiting, diarrhea, and hepatic failure. Precipitants of thyroid storm in a patient with previously compensated thyrotoxicosis include abrupt cessation of antithyroid drugs, thyroid, or nonthyroidal surgery in a patient with unrecognized or inadequately treated thyrotoxicosis, and a number of acute illnesses unrelated to thyroid disease (145). Thyroid storm also occurs rarely following radioactive iodine therapy. Exposure to iodine from the use of iodine-containing contrast agents may be an additional factor in the development of thyroid storm in patients with illnesses unrelated to thyroid disease. Each pharmacologically accessible step in thyroid hormone production and action is targeted in the treatment of patients with thyroid storm (Table 6).

Technical remarks: Treatment with inorganic iodine (SSKI/ Lugol's solution, or oral radiographic contrast) leads to rapid decreases in both T₄ and T₃ levels and combined with antithyroid medication, results in rapid control of Graves' hyperthyroidism, and can aid in severely thyrotoxic patients (146). Unfortunately, the oral radiographic contrast agents ipodate and iopanoic acid are not currently available in many countries.

TABLE 5. POINT SCALE FOR THE DIAGNOSIS OF THYROID STORM

^{Source: Burch and Wartofsky, 1993 (21). Printed with permission.}

TABLE 6. THYROID STORM: DRUGS AND DOSES 

^aMay be given intravenously.