Thyroid stormMANAGEMENT

ENDOCRINE AND METABOLIC PRESENTATIONS · 12 SECTIONS

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488 items

☷ Legend

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Cardiovascular Presentations66▾

Respiratory Presentations47▾

Neurological Presentations77▾

Gastrointestinal Presentations63▾

Genitourinary and Reproductive Presentations44▾

Infectious Disease Presentations146▾

Trauma Presentations88▾

Toxicologic Presentations67▾

Psychiatric Presentations25▾

Musculoskeletal and Rheumatologic Presentations89▾

Dermatology Presentations21▾

Environmental and Exposure Presentations26▾

Hematologic and Oncologic Presentations30▾

Pediatric-Specific Presentations13▾

Endocrine and Metabolic Presentations42▾

Acute Porphyria Adrenal crisis Adrenal Insufficiency (Addisonian Crisis)Dehydration Diabetes Insipidus Diabetic Ketoacidosis (DKA)Galactosemia Homocystinuria Hypercalcemia Hyperkalemia Hypermagnesemia Hypernatremia Hyperosmolar Hyperglycemic State (HHS)Hypertensive emergency Hypertensive urgency Hypocalcemia Hypoglycemia Hypogonadism (Acute Presentation)Hypokalemia Hypomagnesemia Hyponatremia Hypoparathyroidism (Tetany)Maple Syrup Urine Disease (Crisis)Medium-Chain Acyl-CoA Dehydrogenase Deficiency (MCAD)Metabolic Acidosis Metabolic Alkalosis Myasthenia gravis crisis Myxedema coma Pellagra Pheochromocytoma (Crisis)Pituitary Apoplexy Pompe Disease (GSD II)Respiratory Acidosis Respiratory Alkalosis Scurvy SIADH Starvation Ketosis Tarui Disease (GSD VII)Thyroid storm Tyrosinemia Vitamin D Deficiency (Severe-Rickets)Von Gierke Disease (GSD I)

ENT and Maxillofacial Presentations21▾

Ophthalmologic Presentations15▾

Obstetric Presentations17▾

Systemic and Miscellaneous Presentations15▾

01Approach to the Critical Patient/attcp48

Immediate priorities

›Time-critical stabilization

›Airway and ventilation

›High-flow oxygen for hypoxemia

›Early intubation for refractory agitation, hyperthermia, severe acidosis, impending respiratory failure

›Circulation

›Two large-bore IVs

›Cardiac monitor

›Temperature control

›Active external cooling for hyperthermia

›Avoid salicylates for antipyresis

›Early ICU activation

›Persistent hyperthermia

›Shock

›Ventricular arrhythmia

›Altered mental status

Recognition and triggers

›High-risk syndrome recognition

›Thyrotoxic crisis phenotype

›Hyperthermia

›Marked tachycardia

›CNS dysfunction

›Heart failure

›Common precipitants

›Infection

›Thyroid surgery or radioiodine

›Withdrawal of antithyroid therapy

›Iodine load

›Trauma

›Acute coronary syndrome

Monitoring and targets

›Physiologic targets

›Hemodynamics

›Mean arterial pressure appropriate for perfusion

›Heart rate control without shock

›Temperature

›Down-trending core temperature within 1-2 hours

›Avoid overcooling

›Glucose

›Avoid hypoglycemia during high metabolic demand

Early consults

›Specialist coordination

›Endocrinology

›Antithyroid selection and definitive therapy planning

›Critical care

›Vasopressors, ventilation, advanced temperature management

›Cardiology

›Atrial fibrillation with instability

›Refractory rate control

›Surgery

›Suspected thyroiditis abscess

›Consider urgent thyroidectomy in refractory cases

02History/hx34

Presentation pattern

›Classic presentation

›Acute decompensation in known or unrecognized thyrotoxicosis

›Fever

›Palpitations

›Multisystem involvement

›Delirium or agitation

›Dyspnea or edema

Precipitating factors

›Triggers and exposures

›Infection symptoms

›Respiratory

›Urinary

›Recent iodine exposure

›Iodinated contrast

›Amiodarone

›Recent thyroid manipulation

›Surgery

›Biopsy

Thyroid disease context

›Thyroid history

›Graves disease history

›Prior thyroid levels

›Prior orbitopathy

›Toxic nodular goiter history

›Longstanding goiter

›Prior compressive symptoms

Medication history

›Medications and adherence

›Antithyroid drugs

›Missed doses

›Recent dose changes

›Beta-blockers

›Recent discontinuation

›Intolerance

›Drugs that worsen tachycardia

›Sympathomimetics

›Cocaine or stimulants

03Physical Exam/exam33

Vital signs and general

›High-yield findings

›Hyperthermia pattern

›Core temperature elevation

›Diaphoresis

›Cardiovascular stress

›Marked tachycardia

›Wide pulse pressure

Cardiopulmonary

›Cardiac and pulmonary

›Arrhythmia assessment

›Atrial fibrillation

›Ventricular ectopy

›Heart failure signs

›Pulmonary edema

›Elevated JVP

Neurologic and mental status

›CNS involvement

›Agitation or delirium

›Disorientation

›Psychosis

›Severe features

›Seizure

›Coma

Thyroid and eye

›Thyroid exam

›Goiter features

›Diffuse enlargement

›Nodularity

›Thyroid tenderness

›Subacute thyroiditis consideration

›Eye and skin

›Graves features

›Lid lag

›Proptosis

›Pretibial myxedema

›Localized dermopathy

04Differential Diagnosis/ddx31

Life-threatening mimics

›Critical mimics

›Sepsis (ICD-10 A41.9)

›Fever with shock

›Elevated lactate

›Serotonin syndrome (ICD-10 T43.24XA)

›Clonus

›Hyperreflexia

›Neuroleptic malignant syndrome (ICD-10 G21.0)

›Rigidity

›Recent dopamine antagonist exposure

Overlapping hyperthermia syndromes

›Hyperthermia syndromes

›Heat stroke (ICD-10 T67.0)

›Hot dry skin possible

›Environmental exposure

›Malignant hyperthermia (ICD-10 T88.3)

›Peri-anesthetic timing

›Severe rigidity

Cardiac primary processes

›Primary cardiac diagnoses

›Acute coronary syndrome (ICD-10 I21.9)

›Chest pain

›Ischemic ECG

›Decompensated heart failure (ICD-10 I50.9)

›Pulmonary edema

›Low output state

Thyroid-related differentials

›Thyroid causes

›Thyrotoxicosis without storm (ICD-10 E05.90)

›Mild CNS symptoms absent

›Hemodynamic stability

›Thyroiditis (ICD-10 E06.9)

›Tender thyroid

›Elevated ESR or CRP

05Laboratory Tests/lt40

Core labs

›Baseline evaluation

›Thyroid function

›TSH

›Free T4

›Total T3 or free T3

›Metabolic panel

›Sodium

›Potassium

›Creatinine

›Hepatic panel

›AST

›ALT

›Bilirubin

Severity and complications

›Complication screening

›Venous blood gas

›pH

›Lactate mmol/L

›Glucose mmol/L

›Stress hyperglycemia

›Hypoglycemia risk in liver failure

›CBC

›Leukocytosis in infection or stress

›Baseline before thionamides

Etiology and precipitant workup

›Trigger evaluation

›Blood cultures if sepsis concern

›Pre-antibiotic draw if feasible

›Persistent fever despite therapy

›Urinalysis and culture

›Urinary symptoms

›Elderly with delirium

›Respiratory viral testing when relevant

›Influenza season

›COVID-19 circulation

Treatment safety labs

›Medication risk monitoring

›Baseline ANC surrogate

›Neutrophil count

›Fever or sore throat during therapy as agranulocytosis trigger

›Coagulation studies

›INR for hepatic dysfunction

›Procedural planning

06Diagnostic Tests/dt48

Scoring Systems

›Diagnostic support tools

›Burch-Wartofsky Point Scale (BWPS)

›Thermoregulatory dysfunction points

›Increasing points with higher temperature

›High scores support storm likelihood

›CNS effects points

›Agitation or delirium

›Seizure or coma

›Cardiovascular dysfunction points

›Tachycardia severity

›Heart failure severity

›Precipitating event points

›Infection or surgery

›Trauma

›Japanese Thyroid Association criteria

›Thyrotoxicosis requirement

›Elevated free T4 or T3

›Suppressed TSH

›System involvement combinations

›CNS symptoms

›Fever

›Tachycardia

›Heart failure

›GI or hepatic dysfunction

MRI

›MRI indications

›Alternate CNS diagnosis evaluation

›Focal neurologic deficit

›Persistent altered mental status not explained by storm severity

›MRI constraints

›Hemodynamic instability limits feasibility

›Time-sensitive stabilization priority

›CT use cases

›Suspected pulmonary embolism alternative

›Pleuritic pain

›Unexplained hypoxemia

›Intra-abdominal trigger search

›Severe abdominal pain

›Concern for perforation or abscess

Ultrasound (or US)

›Ultrasound applications

›Cardiac POCUS

›LV function

›Pulmonary edema pattern

›Thyroid ultrasound

›Nodular goiter assessment when stable

›Thyroiditis features with tenderness

›Lung ultrasound

›B-lines

›Pleural effusion

07Disposition/dispo18

Level of care

›Disposition decisions

›ICU admission criteria

›BWPS high probability with organ dysfunction

›Need for continuous IV beta-blocker infusion

›Step-down consideration

›Rapid improvement after therapy

›No heart failure

Transfer and escalation

›Transfer triggers

›Lack of ICU capability

›Mechanical ventilation needs

›Refractory shock

›Need for definitive thyroid therapy not available

›Urgent thyroidectomy capability

›Plasmapheresis access for refractory cases

Discharge criteria

›Discharge exceptions

›Thyrotoxicosis without storm only

›Stable vitals after observation

›Reliable follow-up within 24-72 hours

08Treatment/t142

Core strategy and sequence

›Five-pillar treatment sequence

›Supportive care and cooling

›Airway and oxygenation

›Isotonic fluids with cautious titration in heart failure

›Adrenergic blockade

›Rate control goal without hypotension

›Avoid isolated calcium channel blocker in shock

›Thionamide to block synthesis

›PTU or methimazole selection

›Early administration priority

›Iodine to block release

›After thionamide timing

›Avoid before thionamide in most cases

›Glucocorticoid to reduce T4 to T3 and treat adrenal insufficiency risk

›Hydrocortisone preferred

›Stress-dose strategy

Antipyresis and cooling

›Temperature management

›Cooling modalities

›Cooling blankets

›Ice packs to groin and axilla

›Antipyresis

›Acetaminophen dosing per local protocol

›Avoid aspirin and salicylates

Beta-blockade

›Adrenergic blockade options

›Propranolol PO or IV

›Typical strategy

›Oral dosing in stable patients

›IV dosing for rapid control in monitored setting

›Additional benefit

›Reduced peripheral T4 to T3 conversion at higher doses

›Esmolol IV infusion

›Initiate for severe tachycardia with titratable short half-life

›Loading bolus per local protocol

›Continuous infusion titration every 5-15 minutes

›Stop if hypotension or worsening shock

›Transition to alternative rate control

›Vasopressor support if needed

›Contraindications and cautions

›Decompensated heart failure

›Asthma with bronchospasm

›Shock or low output state

Thionamides

›Antithyroid drugs

›Propylthiouracil (PTU)

›Dosing strategy

›Loading dose then scheduled dosing

›Enteral route preferred when possible

›Rationale

›Blocks thyroid hormone synthesis

›Decreases peripheral T4 to T3 conversion

›Safety considerations

›Hepatotoxicity risk

›CBC and LFT monitoring

›Methimazole

›Dosing strategy

›High-dose scheduled regimen

›Enteral route preferred when possible

›Rationale

›Blocks thyroid hormone synthesis

›Lower severe hepatotoxicity risk than PTU in many settings

›Pregnancy note

›Avoid in first trimester when possible

›Preferred in second and third trimester

Iodine therapy

›Iodine blockade

›Timing

›Administer at least 1 hour after thionamide when feasible

›Earlier use if life-threatening and thionamide delayed only with specialist input

›Formulations

›Potassium iodide solution

›Lugol solution

›Iodinated contrast effect acknowledgement

›Contraindications and pitfalls

›Iodine allergy is not equivalent to contrast reaction history

›Use caution in toxic nodular disease with recent iodine load

Glucocorticoids

›Steroid therapy

›Hydrocortisone IV

›Stress-dose regimen

›Scheduled dosing for first 24-48 hours

›Taper as clinical improvement occurs

›Rationale

›Reduced peripheral T4 to T3 conversion

›Relative adrenal insufficiency coverage

›Dexamethasone IV alternative

›Use when mineralocorticoid effect undesirable

›Longer half-life allows less frequent dosing

Adjunctive therapies

›Additional hormone-lowering options

›Cholestyramine

›Enteral adjunct for severe cases

›Binds thyroid hormones in gut

›Shortens hormone half-life

›Separation from other oral meds

›Dose spacing to avoid reduced absorption

›Lithium carbonate

›Consider when thionamides contraindicated

›Blocks hormone release

›Narrow therapeutic window

›Monitoring needs

›Serum lithium levels

›Renal function

›Plasmapheresis

›Consider for refractory storm

›Severe hepatic failure limiting drug options

›Bridge to thyroidectomy

Arrhythmia and heart failure management

›Cardiovascular complications

›Atrial fibrillation

›Beta-blocker first-line when hemodynamically tolerated

›Esmolol in ICU setting

›Propranolol in stable setting

›Digoxin considerations

›Reduced efficacy in thyrotoxicosis

›Higher dose requirements increase toxicity risk

›Amiodarone considerations

›Iodine load may worsen thyroid status

›Use only with specialist input for life-threatening arrhythmia

›Heart failure

›Diuretics for pulmonary edema

›Loop diuretic titration based on response

›Monitor electrolytes

›Vasopressors for shock

›Norepinephrine as typical first-line in distributive physiology

›Avoid excessive beta-agonism when possible

Antibiotics and trigger treatment

›Precipitant-directed therapy

›Sepsis bundle when suspected

›Early broad-spectrum antibiotics

›Source control plan

›ACS management when suspected

›ECG-guided therapy

›Troponin trend and cardiology input

Evidence levels

›Evidence grading notes

›ACEP clinical policy specific to thyroid storm not established

›Many interventions based on endocrine society guidance and expert consensus

›ACEP Level C style evidence alignment for ED pathways in absence of RCTs

›Class recommendations framework

›Class I

›Supportive care and cooling for hyperthermia

›Beta-blockade when hemodynamically tolerated

›Thionamide then iodine sequence

›Glucocorticoids early in severe storm

›Class IIa

›Cholestyramine adjunct in severe cases

›Esmolol infusion for titratable control in ICU

›Class IIb

›Plasmapheresis for refractory cases as bridge to definitive therapy

09Special Populations/sp30

Pregnancy

›Pregnancy considerations

›Maternal-fetal risks

›Preterm labor risk

›Fetal tachycardia risk

›Antithyroid selection

›PTU preferred in first trimester

›Methimazole preferred after first trimester

›Beta-blocker cautions

›Fetal growth restriction with prolonged use

›Neonatal bradycardia risk

Geriatric

›Older adult considerations

›Atypical presentation

›Afebrile storm possible

›Predominant heart failure

›Medication sensitivity

›Lower beta-blocker tolerance

›Higher delirium risk with sedatives

›Comorbidity triggers

›Pneumonia

›Atrial fibrillation onset

Pediatrics

›Pediatric considerations

›Weight-based dosing

›Thionamide dosing per kg

›Beta-blocker dosing per kg

›Etiologies

›Graves disease most common

›Thyroiditis less common

›Monitoring intensity

›Rapid decompensation risk

›Early ICU involvement threshold lower

10Background/b33

Epidemiology

›Population patterns

›Rarity

›Uncommon complication of thyrotoxicosis

›Higher risk with untreated Graves disease

›Mortality

›High mortality without rapid recognition and treatment

›Outcomes improve with early ICU-level care

›Coding alignment

›ICD-10 E05.01 thyrotoxicosis with diffuse goiter with thyrotoxic crisis or storm

›ICD-10 E05.11 toxic single thyroid nodule with thyrotoxic crisis or storm

Pathophysiology

›Mechanistic framework

›Excess circulating thyroid hormone effect

›Increased beta-adrenergic receptor expression

›Increased metabolic rate and heat production

›Decompensation model

›Precipitant increases hormone release or demand

›Limited cardiovascular reserve leads to failure

›Organ dysfunction pathways

›High-output heart failure progression

›Hepatic hypoperfusion and cholestasis

Therapeutic Considerations

›Rationale for sequencing

›Thionamide before iodine

›Prevents iodine-driven hormone synthesis

›Supports Wolff-Chaikoff benefit while limiting substrate effect

›Beta-blockade early

›Symptom control and arrhythmia prevention

›Avoids catecholamine-mediated injury

›Steroids early

›Reduced T4 to T3 conversion

›Adrenal support in critical illness

›Definitive therapy planning

›Radioiodine timing after stabilization

›Thyroidectomy consideration for refractory storm or contraindications

11Patient Discharge Instructions/pdi17

Copy discharge instructions

›Discharge instructions template

›Diagnosis clarification

›Thyrotoxicosis without storm diagnosis only

›Thyroid storm requires admission and ICU monitoring

›Medications

›Antithyroid medication adherence as prescribed

›Beta-blocker adherence as prescribed

›Return to ED now

›Fever

›Chest pain

›Shortness of breath

›Fainting

›Confusion or severe agitation

›Persistent vomiting

›Follow-up

›Endocrinology follow-up within 24-72 hours

›Repeat thyroid labs per plan

12References/r14

Clinical guidelines and consensus

›Key guidance sources

›American Thyroid Association guidance on thyrotoxicosis and antithyroid drugs

›PTU versus methimazole pregnancy recommendations

›Agranulocytosis counseling emphasis

›Japanese Thyroid Association criteria for thyroid storm

›Diagnostic combinations with thyrotoxicosis requirement

›Severity stratification supporting ICU care

Evidence-based sources

›Evidence base

›Burch-Wartofsky Point Scale primary description

›Multisystem point-based probability approach

›Use as adjunct, not replacement for clinical judgment

›Reviews and critical care summaries on storm treatment sequencing

›Thionamide then iodine consensus sequence

›Steroid role in T4 to T3 reduction

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Reviewed by SymptomDx Medical Team · Last reviewed June 16, 2026

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