Thyroid Storm

  • Santosh Vaghela
  • Robyn ScatenaEmail author


Thyroid storm represents the severe end of the spectrum of thyrotoxicosis and is characterized by compromised organ function. It is one of the most critical endocrine emergencies; prompt recognition and management are crucial to reduce morbidity and mortality. The mortality rate of thyroid storm can be substantial, ranging from 10% to 30% of cases. In this chapter the pertinent principles of management will be reviewed. We will also review the common precipitating factors and hypotheses regarding the development of thyroid storm. Patient presentation, diagnosis, and treatment will be examined, along with diagnostic scoring tools and specific medications used in the management of thyroid storm. As part of the evidence contour we will assess other less commonly used therapies for thyroid storm, including l-Carnitine and extracorporeal plasmapheresis.


Thyroid storm TSH (thyroid stimulating hormone) Free T3 (triiodothyronine) Free T4 (thyroxine) Propranolol Thionamide Propylthiouracil (PTU) Methimazole Burch and Wartofsky Plasmapheresis l-carnitine 


  1. 1.
    Nylen ES, Alarifi AA. Humoral markers of severity and prognosis of critical illness. Best Pract Res Clin Endocrinol Metab. 2001;15:553–73.CrossRefGoogle Scholar
  2. 2.
    Dillmann WH. Thyroid storm. Curr Ther Endocrinol Metab. 1997;6:81–5.PubMedGoogle Scholar
  3. 3.
    Akamizu T, Satoh T, Iozaki O, Suzuki A, Wakino S, Iburi T, et al. Diagnostic criteria, clinical features, and incidence of thyroid storm based on nationwide surveys. Thyroid. 2012;22:661–79.CrossRefGoogle Scholar
  4. 4.
    Burch HB, Wartofsky L. Life-threatening thyrotoxicosis. Thyroid storm. Endocrinol Metab Clin N Am. 1993;22:263–77.CrossRefGoogle Scholar
  5. 5.
    Sarlis NJ, Gourgiotis L. Thyroid emergencies. Rev Endocr Metab Disord. 2003;4:129–36.CrossRefGoogle Scholar
  6. 6.
    Papi G, Corsello SM, Pontecorvi A. Clinical concepts on thyroid emergencies. Front Endocrinol. 2014;5:102.CrossRefGoogle Scholar
  7. 7.
    Chong HW, See KC, Phua J. Thyroid storm with multiorgan failure. Thyroid. 2010;20:333–6.CrossRefGoogle Scholar
  8. 8.
    Jiang YZ, Hutchinson KA, Bartelloni P, Manthous CA. Thyroid storm presenting as multiple organ dysfunction syndrome. Chest. 2000;118:877–9.CrossRefGoogle Scholar
  9. 9.
    Martinez-Diaz GJ, Formaker C, Hsia R. Atrial fibrillation from thyroid storm. J Emerg Med. 2012;42:e7–9.CrossRefGoogle Scholar
  10. 10.
    Kobayashi C. Severe starvation hypoglycemia and congestive heart failure induced by thyroid crisis, with accidentally induced severe liver dysfunction and disseminated intravascular coagulation. Intern Med. 2005;44:234–9.CrossRefGoogle Scholar
  11. 11.
    Abbasi B, Sharif Z, Sprabery LR. Hypokalemic thyrotoxic periodic paralysis with thyrotoxic psychosis and hypercapnic respiratory failure. Am J Med Sci. 2010;340:147–53.CrossRefGoogle Scholar
  12. 12.
    Hsiao FC, Hung YJ, Hsieh CH, Wu LY, Shih KC, He CT. Abdominal pain and multiorgan dysfunction syndrome in a young woman. Am J Med Sci. 2007;334:399–401.CrossRefGoogle Scholar
  13. 13.
    Ngo SY, Chew HC. When the storm passes unnoticed – a case series of thyroid storm. Resuscitation. 2007;73:555.CrossRefGoogle Scholar
  14. 14.
    Bajwa SS, Jindal R. Endocrine emergencies in critically ill patients: challenges in diagnosis and management. Indian J Endocrinol Metab. 2012;16:722–7.CrossRefGoogle Scholar
  15. 15.
    Ross DS. Thyroid storm. In: Cooper DS, editor. UpToDate. Waltham: UpToDate. Accessed 14 Jan 2015.Google Scholar
  16. 16.
    Pimental L, Hansen KN. Thyroid disease in the emergency department: a clinical and laboratory review. J Emerg Med. 2005;28:201–9.CrossRefGoogle Scholar
  17. 17.
    Nayak B, Burman K. Thyrotoxicosis and thyroid storm. Endocrinol Metab Clin N Am. 2006;35:663–86.CrossRefGoogle Scholar
  18. 18.
    Hull K, Horenstein R, Naglieri R, Munir K, Ghany M, Celi FS. Two cases of thyroid storm-associated cholestatic jaundice. Endocr Pract. 2007;13:476–80.CrossRefGoogle Scholar
  19. 19.
    Brunette DD, Rothong C. Emergency department management of thyrotoxic crisis with esmolol. Am J Emerg Med. 1991;9:232–4.CrossRefGoogle Scholar
  20. 20.
    Cooper DS, Saxe VC, Meskell M, et al. Acute effects of propylthiouracil (PTU) on thyroidal iodide organification and peripheral iodothyronine deiodination: correlation with serum PTU levels measured by radioimmunoassay. J Clin Endocrinol Metab. 1982;54:101–7.CrossRefGoogle Scholar
  21. 21.
    Nabil N, Miner DJ, Amatruda JM. Methimazole: an alternative route of administration. J Clin Endocrinol Metab. 1982;54:180–1.CrossRefGoogle Scholar
  22. 22.
    Walter RM Jr, Bartle WR. Rectal administration of propylthiouracil in the treatment of graves’ disease. Am J Med. 1990;88:69–70.CrossRefGoogle Scholar
  23. 23.
    Langley RW, Burch HB. Perioperative management of the thyrotoxic patient. Endocrinol Metab Clin N Am. 2003;32:519–34.CrossRefGoogle Scholar
  24. 24.
    Liaw YF, Huang MJ, Fan KD, Li KL, Wu SS, Chen TJ. Hepatic injury during propylthiouracil therapy in patients with hyperthyroidism. A cohort study. Ann Intern Med. 1993;118(6):424–8.CrossRefGoogle Scholar
  25. 25.
    Vickers P, Garg KM, Arya R, Godha U, Mathur P, Jain S. The role of selective beta 1-blocker in the preoperative preparation of thyrotoxicosis: a comparative study with propranolol. Int Surg. 1990;75(3):179–83.PubMedGoogle Scholar
  26. 26.
    Kinoshita H, Yasuda M, Furumoto Y, et al. Severe duodenal hemorrhage induced by Lugol’s solution administered for thyroid crisis treatment. Intern Med. 2010;49:759–61.CrossRefGoogle Scholar
  27. 27.
    Tsatsoulis A, Johnson EO, Kalogera CH, et al. The effect of thyrotoxicosis on adrenocortical reserve. Eur J Endocrinol. 2000;142:231.CrossRefGoogle Scholar
  28. 28.
    Mazzaferri EL, Skillman TG. Thyroid storm. A review of 22 episodes with special emphasis on the use of guanethidine. Arch Intern Med. 1969;124:684–90.CrossRefGoogle Scholar
  29. 29.
    Kaykhaei MA, Shams M, Sadegholvad A, et al. Low doses of cholestyramine in the treatment of hyperthyroidism. Endocrine. 2008;34:52–5.CrossRefGoogle Scholar
  30. 30.
    Ross DS. Iodinated radiocontrast agents in the treatment of hyperthyroidism. In: Cooper DS, editor. UpToDate. Waltham: UpToDate. Accessed 16 Jan 2015.Google Scholar
  31. 31.
    Caldwell G, Errington M, Toft AD. Resistant hyperthyroidism induced by sodium iopodate used as treatment for Graves’ disease. Acta Endocrinol. 1989;120:215–6.CrossRefGoogle Scholar
  32. 32.
    Vyas AA, Vyas P, Fillipon NL, et al. Successful treatment of thyroid storm with plasmapheresis in a patient with methimazole induced agranulocytosis. Endocr Pract. 2010;16:673–6.CrossRefGoogle Scholar
  33. 33.
    Benvenga S, Lapa D, Cannavo S, Trimarchi F. Successive thyroid storm treated with L-carnitine and low doses of methimazole. Am J Med. 2003;115:417–8.CrossRefGoogle Scholar
  34. 34.
    Benvenga S, Ruggeri RM, Russo A, Lapa D, Campenni A, Trimarchi F. Usefulness of L-carnitine, a naturally occurring peripheral antagonist of thyroid hormone action, in iatrogenic hyperthyroidism: a randomized, double-blind, placebo-controlled clinical trial. J Clin Endocrinol Metab. 2001;86:3579–94.CrossRefGoogle Scholar
  35. 35.
    Reyes-Castano JJ, Burman K. Thyrotoxic crisis: thyroid storm. In: Loriaux L, editor. Endocrine Emergencies. Contemporary Endocrinology, vol. 74. Totowa, NJ: Humana Press; 2014.Google Scholar

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  1. 1.Section of Pulmonary, Critical Care and Sleep MedicineNorwalk HospitalNorwalkUSA
  2. 2.Yale University School of MedicineNew HavenUSA

Personalised recommendations