This document discusses the management of thyroid storm, a life-threatening condition characterized by a hypermetabolic state caused by underlying hyperthyroidism. Key points include: - Thyroid storm is diagnosed clinically or using scoring tools like the Burch-Wartofsky Point Scale. - Management aims to inhibit thyroid hormone synthesis/release and peripheral effects while reversing decompensation. This involves high-dose antithyroid drugs, beta blockers, corticosteroids, inorganic iodide, and treating any precipitating factors. - Supportive treatments like IV fluids and nutrition are also important, along with considering urgent thyroidectomy or radioactive iodine in some cases. Patient education is crucial

1. MANAGEMENT OF THYROID
STORM
BY DR GEETHA SUBRAHAMANIAM
CME OF NUCLEAR MEDICINE
29TH SEPTEMBER 2021

2. DEFINITION
Mortality 11-25%
(especially if you miss it)
Characterized by a multisystem disorder by
triggering event in conjunction with underlying
hyperthyroid conditions.

3. WHO DOES IT HAPPEN TO ?
Underlying thyroid disorders
• Grave’s disease
• Multinodular Goitre
• Hashimoto
• Thyroid adenoma
• Administration of iodinated contrast/radioactive iodine
• Diabetic ketoacidosis
• Severe Infection/sepsis
• Cardiac event
• Thyroidal or non-thyroidal surgery
• Trauma
• Pregnancy/post natal
• Adrenal insufficiency
Untreated / Undiagnosed/ Non-
compliant/discontinuation ATH

4. PATHOPHYSIOLOGY

5. DIAGNOSIS OF THYROID STORM
• MADE CLINICALLY IN A THYROTOXIC PATIENT WITH EVIDENCE OF
DECOMPENSTATION, ITS OFTEN OVERLAP WITH CLINICAL FEATURES OF OTHER
CRITICAL MEDICAL CONDITIONS
• AID DIAGNOSTIC METHODS
• BURCH–WARTOFSKY POINT SCALE (RECOMMENDED TOOL, MORE SENSITIVE)
• THE NEWER JAPAN THYROID ASSOCIATION

6. BURCH–WARTOFSKY POINT SCALE
Score
• more/equal 45
thyroid storm
• 25-44 : Impending
thyroid storm
• <25 : Thyroid
storm unlikely
Score of 25-44,
requires clinical
judgement to look
for decompensation

7. THE NEWER JAPAN THYROID ASSOCIATION
*Grade TS2 :
requires clinical
judgement to
look for
decompensatio
n

8. MANAGEMENT
AIM OF MANAGEMENT OF THYROID STORM ;
• INHIBITING SYNTHESIS AND RELEASE OF THYROID HORMONE
• INHIBITING PERIPHERAL ACTION OF THYROID HORMONE
• REVERSING SYSTEMIC DECOMPENSATION
• TREATING PRECIPITATING EVENT
• ADDRESSING DEFINITIVE THERAPHY

9. ANTI-THYROID DRUG: MMI/PTU
• HIGH DOSE OF PROPYLTHIOURACIL(PTU) RECOMMENDED, WITH LOADING DOSE 500-1000MG THEN
250MG 4H
• IN THE PRESENCE OF CONTRAINDICATIONS, HIGH DOSE OF METHIMAZOLE (MMI) 60-80MG/DAY,
SINGLE DOSE OR DIVIDED INTO TWO EQUAL DOSES.
• PTU IS PREFERRABLY USED FOR COMPARED TO MMI IN THYROID STORM, AS LATTER HAS THE ADDED
BENEFITS OF INHIBITING TYPE 1 DEIODINASE ACTIVITY IN THE THYROID GLAND AND OTHER
PERIPHERAL ORGANS( REDUCE THE CONVERSION OF T4 TO T3), T3 LEVELS DROP BY 45% WITHIN
ONE HOUR OF PTU ADMINISTRATION BUT ONLY ABOUT 10-15% AFTER STARTING MMI.
• NO OUTCOME DIFFERENCES BETWEEN MMI AND PTU
ADJUVANT TREATMENT FOR THYROID STORM
LITHIUM CAN BE USED ALTERNATIVE FOR PATIENT WHO CANNOT TOLERATE MMI/PTU.
• WORKS BY INHIBITING RELEASE OF THYROID HORMONE BY THYROID GLAND THROUGH UNKOWN
MECHANISM
• DOSE: 300MG TDS, MONITORED LITHIUM TOXICITY

11. BETA ADRENERGIC RECEPTOR ANTAGONISTS.
• KEY TO CONTROL HEART RATE AND INHIBIT OTHER PERIPHERAL ACTIONS OF
THYROID HORMONES IN THYROID STORM.
• ABILITY INHIBITS TYPE 1 DEIODINASE SUCH AS PROPRANOLOL, 60-80MG/4H
• BETA BLOCKERS WITH SELECTIVE B-1 BLOCKADE SUCH AS BISOPROLOL,
LANDIOLOL AND ESMOLOL INFUSION HAVE MORE FAVORABLE CVS BENEFITS IN
THYROID STORM WITH CARDIAC COMPROMISE.
• IV ESMOLOL LOADING DOSE 250-500MCG , MAINTAINANCE 50-1OOMCG/KG/MIN
• CONTRAINDICATIONS TO BETA BLOCKERS SUCH AS PATIENT WITH BRONCHIAL
ASTHMA OR COPD, DILTIAZEM CAN BE USED IN INTENSIVE CARE SETTING TO
CONTROL HR.
• AF PATIENT, CARDIOVERSION CONSIDERED AFTER R/OUT CARDIAC THROMBOSIS
IF HEMODYNAMICS ARE IMPAIRED.

12. CORTICOSTEROIDS
• TO INHIBIT BOTH THYROID HORMONE SYNTHESIS AND PERIPHERAL CONVERSION
OF T4-T3
• GIVEN AS PROPHYLAXIS FOR RELATIVE ADRENAL INSUFFICIENCY CAUSED BY
HYPERMETABOLIC STATE IN THYROID STORM.
• IV IS PREFERRED WHEN RAPID REACTION IS PREFFERED , WITH THE
IMPROVEMENT IN CLINICAL CONDITION DOSES SHOULD BE REDUCED AND
TAPERED OFF TO PREVENT ADVERSE EFFECT.
• DEXAMETHASONE (MEDIAN DOSE 6MG/DAY)
• HYDROCORTISONE (300MG/DAY)
• PREDNISALONE (25MG/DAY)

13. INORGANIC IODIDE(LUGOL’S IODINE/SATURATED SOLUTIONS OF POTASSIUM
IODIDE,SSKI)
• USED TO DECREASE T4 LEVELS BY INHIBITION OF IODIDE OXIDATION AND
ORGANIFICATION AND INHIBITS RELEASE OF THYROID HORMONE.
• RECOMMENDED DOSE 5DROPS OF LUGOL’S IODIDE 6H(6.25MG IODINE/DROP) OR
10DROPS OF LUGOL’S IODINE 8H
• THIS SOLUTION SHOULD BE DILUTED IN WATER OR TAKEN WITH BREAD TO AVOID
MUCUSAL IRRITATION.
• THIS AGENTS CAN BE USED IN COMBINATION WITH ATT.
• THESE AGENTS SHOULD ONLY BE GIVEN AT LEAST AFTER ONE HOUR OF ATT
DRUGS ADMINISTRATION, TO PREVENT USE OF IODINE AS SUBTRATE FOR
THYROID HORMONE SYNTHESIS.
• AFTER CLINICAL IMPROVEMENT, THE LUGOL’S SHOULD BE TAPERED AND
STOPPED BEFORE THE ANTITHYROID.
• LUGOL’S IODINE SHOULD NOT GIVEN BEYOND 10DAYS OR ELSE THIS WOULD
LEAD TO ESCAPE FROM WOLFF-CHAIKOFF PHENOMENON.
• CONTRAINDICATED: KNOWN TO BE ALLERGIC TO INORGANIC IODIDE

15. SUPPORTIVE TREATMENT
• INTRAVENOUS FLUIDS
• RESPIRATORY SUPPORT INCLUDES INVASSIVE/NON-INVASSIVE
• NUTRITIONAL SUPPORT
• ACUTE INFECTIONS- SHOULD BE TREATED WITH BROAD SPECTRUM ABX
DEFINITIVE THERAPHY
URGENT/ EARLY THYROIDECTOMY
• IS AN OPTION IN PATIENTS WHO HAVE CONTRAINDICATIONS TO ATT, LARGE GOITRE
• PATIENTS SHOULD RENDERED TO EUTHYROID STATE PRIOR TO SURGERY TO MINIMISE RISK OF
THYROID STORM
• RAI IODINE IS CONSIDERED AND LUGOL’S IODINE HAS BEEN ADMINISTERED DURING THYROID STORM ,
THE RAI SHOULD BE DEFERRED UNTIL ABOUT 3-4 MONTHS AFTER.
PRECIPATING FACTORS: NON-COMPLIANCE
• PATIENT SHOULD BE EDUCATED ON THIS ASPECT