Thyroid storm

It is an exaggerated presentation of thyrotoxicosis.
It comes with sudden multisystem involvement.
The mortality associated with thyroid storm is estimated to be 8-25% despite modern advancements in its treatment and supportive measures

Untreated/Undertreated Disease: Medication non-compliance. Abrupt discontinuation of antithyroid medicine
Physical Stress: Trauma, surgery (thyroid or non-thyroid), myocardial infarction/ischemia.
Acute illness: diabetic ketoacidosis, acute myocardial infarction, cardiovascular accident, cardiac failure, drug reaction
Infections: General infections, diabetic ketoacidosis/hyperosmolar nonketotic coma.
Iodine Exposure: Iodinated contrast in susceptible patients.
Ingestion: Excess thyroid hormone.

Hormone Dynamics: T4 is deiodinated to T3 (more active form).
Protein Binding: >99% of thyroid hormone is protein-bound (inactive); only free hormone is active.
Metabolic Effects: Affects metabolism in all tissues; increases beta-adrenergic receptor expression and sensitivity.
Iodine Effects: Wolff-Chaikoff effect (excess iodide inhibits hormone release), Jod-Basedow effect (iodide load induces hyperthyroidism).

Organ System	Symptoms	Signs
CNS	Anxiety confusion delirium	Hyperreflexia seizures coma
	psychosis, lethargy
Cardiovascular	Palpitations chest pain dyspnoea	Sinus tachycardia atrial fibrillation
	on exertion	widened pulse pressure heart failure
Gastrointestinal	Abdominal pain nausea vomiting	Diarrhea jaundice
	diarrhea
Thyroid Gland	Neck fullness	Tenderness diffuse enlargement bruit

Clinical Evaluation: Based on symptoms; serum testing is unreliable in acute states.
Burch-Wartofsky Scale: Commonly used system for rapid recognition and diagnosis.
Laboratory Findings: Low TSH, elevated T3/T4, hyperkalemia, hyponatremia, anemia, thrombocytopenia, low serum creatinine, hypercalcemia.

Initial Stabilization:
- Evaluate airway and breathing
- establish IV access
- cardiac monitoring
- active cooling measures
- empiric fluid administration
- empiric broad-spectrum antibiotics
Specific Treatments:
- Beta Blockers: Propranolol (0.5-1 mg IV, repeat q5-10 min, titrate to HR < 100), Esmolol as an alternative.
- Thionamides: Propylthiouracil (PTU) (600-1000 mg PO load, 300 mg PO q6h), Methimazole (20-30 mg q6h).
- Corticosteroids: Hydrocortisone (100 mg IV q8h), Dexamethasone (2-4 mg IV q6h).
- Inorganic Iodine: Potassium iodide (SSKI) (5 gtt q6h), Lugol’s solution (4-8 gtt q6h), Lithium (300 mg q6-8h).
- Additional Interventions: Cholestyramine (4 g PO q6h), L-Carnitine (1 g PO q12h).

Clinical Diagnosis: Suspect in patients with fever, altered mental status.
Rapid Diagnosis: Use Burch-Wartofsky scale for quick initiation of treatment.
Broad Spectrum Antibiotics: Consider due to frequent concomitant infections.
Directed Management: Beta blockade followed by corticosteroids, thionamides, and inorganic iodine.