Suspected Thyroid Storm
Severe thyrotoxicosis with systemic decompensation
All Pathways
EndocrinologyEmergency
Thyroid Storm Management
Thyroid Storm Management: Suspected Thyroid Storm → Calculate Burch-Wartofsky Point Scale → BWPS Score Interpretation → 1. Immediate Stabilization → 2. ...
Pathway Overview
13 steps
Algorithm Steps
13 total
01Start 02Action Calculate Burch-Wartofsky Point Scale
Diagnostic scoring system
- Temperature: 99-99.9°F (+5), 100-100.9°F (+10), 101-101.9°F (+15), 102-102.9°F (+20), 103-103.9°F (+25), ≥104°F (+30)
- CNS: Absent (0), Mild agitation (+10), Moderate: delirium/psychosis (+20), Severe: seizure/coma (+30)
- GI/Hepatic: Absent (0), Moderate: diarrhea/N/V (+10), Severe: jaundice (+20)
- Heart Rate: 90-109 (+5), 110-119 (+10), 120-129 (+15), 130-139 (+20), ≥140 (+25)
- Heart Failure: Absent (0), Mild: edema (+5), Moderate: bibasilar rales (+10), Severe: pulm edema (+15)
- Atrial Fibrillation: Absent (0), Present (+10)
- Precipitating Event: Absent (0), Present (+10)
03Decision BWPS Score Interpretation
Determine likelihood of thyroid storm
- ≥45: Highly suggestive of thyroid storm
- 25-44: Impending thyroid storm
- <25: Thyroid storm unlikely
04Action 1. Immediate Stabilization
ICU admission, supportive care
- ICU admission mandatory
- IV access, cardiac monitoring, pulse oximetry
- Cooling measures for hyperthermia (avoid aspirin)
- IV fluids for volume depletion
- Treat precipitating cause
- Consider central line for access
05Action 2. Beta-Blockade
Control adrenergic symptoms - beta-1 selective preferred
- Esmolol 250-500 mcg/kg IV bolus, then 50-100 mcg/kg/min (PREFERRED)
- OR Landiolol (ultra-short acting, Japan guideline preferred)
- OR Propranolol 60-80 mg PO q4-6h (blocks T4→T3 but higher mortality in CHF)
- ⚠️ Japan data: Propranolol associated with 7.6x increased mortality in Killip IV CHF
- Target HR <100 bpm
- Use beta-1 selective agents in any cardiac compromise
06Action 4. Iodine Therapy
Block thyroid hormone release (give 1h AFTER thionamide)
- Lugol's solution: 4-8 drops PO q6-8h
- OR SSKI: 5 drops PO q6h
- OR Sodium iodide: 500-1000 mg IV q12h
- If iodine allergic: Lithium 300 mg PO q8h
- MUST give 1 hour AFTER thionamide to prevent iodine utilization
07Action 5. Glucocorticoids
Block T4→T3 conversion, treat relative adrenal insufficiency
- Hydrocortisone 100 mg IV q8h
- OR Dexamethasone 2 mg IV q6h
- Treats associated adrenal insufficiency
- Inhibits peripheral T4→T3 conversion
- Continue until stable
08Action 6. Continuous Monitoring
Close assessment in ICU
- Cardiac telemetry (AFib, heart failure)
- Temperature q1-2h
- Neurologic status
- Fluid balance
- Labs: TSH, free T4, CBC, LFTs, electrolytes
- Watch for LFT abnormalities with PTU
09Decision Response to Treatment?
Assess after 24-48 hours
10Outcome Clinical Improvement
Continue therapy, plan definitive treatment
- Continue medications
- Taper as tolerated
- Plan definitive therapy: RAI or thyroidectomy
- Transition to outpatient management
11Warning Refractory Storm
Consider additional measures
- Plasmapheresis/plasma exchange
- Cholestyramine 4g PO QID (binds thyroid hormone)
- Emergency thyroidectomy (rare)
- ECMO if cardiovascular collapse
12Warning ⚠️ CRITICAL: Beta-Blocker in Heart Failure
Non-selective beta-blockers increase mortality
- AVOID propranolol in CHF - Japan surveys show 7.6x increased mortality
- Use esmolol or landiolol (short-acting, beta-1 selective) if HF present
- Some patients with thyroid storm may arrest with any beta-blocker
- Consider digoxin for rate control (higher doses needed - increased clearance)
- Risk-benefit: undertreating tachycardia vs precipitating arrest
13Action 3. Antithyroid Drugs
Block thyroid hormone synthesis
- Propylthiouracil (PTU) 500-1000 mg loading, then 250 mg q4h
- OR Methimazole 60-80 mg/day in divided doses
- PTU preferred (also blocks T4→T3 conversion)
- Give BEFORE iodine (1 hour)
- PTU preferred in 1st trimester pregnancy
- Path rejoins step 06Shared downstream outcome
Guideline Source
2016 Guidelines for the Management of Thyroid Storm from The Japan Thyroid Association and Japan Endocrine Society
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Does not address pediatric thyroid storm
- Propylthiouracil preferred in pregnancy (first trimester)
- Requires ICU-level monitoring
- Does not cover post-thyroidectomy storm in detail
Contraindicated Populations
pediatric
Applicable Regions
USEUJapan
US: ATA 2016 hyperthyroidism guidelines also apply
Japan: JTA criteria validated in Japanese population
Version 1Next review: 2027-01-01
Next steps
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Related Resources
Frequently Asked Questions
What is the Thyroid Storm Management?
The Thyroid Storm Management is a emergency clinical algorithm for Endocrinology. It provides a structured decision tree to guide clinical decision-making, based on 2016 Guidelines for the Management of Thyroid Storm from The Japan Thyroid Association and Japan Endocrine Society.
What guideline is the Thyroid Storm Management based on?
This algorithm is based on 2016 Guidelines for the Management of Thyroid Storm from The Japan Thyroid Association and Japan Endocrine Society (DOI: 10.1507/endocrj.EJ16-0336).
What are the limitations of the Thyroid Storm Management?
Known limitations include: Does not address pediatric thyroid storm; Propylthiouracil preferred in pregnancy (first trimester); Requires ICU-level monitoring; Does not cover post-thyroidectomy storm in detail. Individual patient factors may require deviation from these recommendations.
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