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Thyroid storm

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of thyroid storm are prepared by our editorial team based on guidelines from the American Society for Apheresis (ASFA 2019), the European Thyroid Association (ETA 2018), the American Thyroid Association (ATA 2016), and the Japan Thyroid Association (JTA/JES 2016). ...
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Screening and diagnosis

Diagnostic criteria
As per ATA 2016 guidelines:
Diagnose thyroid storm clinically in a severely thyrotoxic patient with evidence of systemic decompensation.
B
Consider using a sensitive diagnostic system (such as the Burch-Wartofsky Point Scale) as an adjunct to diagnosis.
B
Burch-Wartofsky Point Scale for thyroid storm (BWPS)
Temperature, °C [°F]
< 37.2 [< 99]
37.2-37.7 [99-99.9]
37.8-38.2 [100-100.9]
38.3-38.8 [101-101.9]
38.9-39.2 [102-102.9]
39.3-39.9 [103-103.9]
≥ 40.0 [≥ 104.0]
HR, bpm
< 90
90-109
110-119
120-129
130-139
≥ 140
Congestive HF
Absent
Mild
Moderate
Severe
AF
Yes
No
CNS disturbance
Absent
Mild: agitation
Moderate: delirium, psychosis, extreme lethargy
Severe: seizure, coma
Gastrointestinal-hepatic dysfunction
Absent
Moderate
Severe
Precipitating event
Yes
No
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Classification and risk stratification

Risk stratification: as per ATA 2016 guidelines, risk stratify patients using a validated scale. Patients with a Burch-Wartofsky Point Scale of ≥ 45 and evidence of systemic decompensation require aggressive therapy. The decision to use aggressive therapy in patients with a Burch-Wartofsky Point Scale of 25-44 should be based on clinical judgment.
B

Medical management

Setting of care: as per JES/JTA 2016 guidelines, transfer patients with highly suspected thyroid storm based on diagnostic criteria to a general hospital with an ICU and specialists in endocrinology and other subspecialties.
B
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More topics in this section

  • General principles

  • Pharmacotherapy (antithyroid drugs)

  • Pharmacotherapy (corticosteroids)

  • Pharmacotherapy (beta-blockers)

  • Pharmacotherapy (inorganic iodide)

  • Supportive care

  • Management of complications (AF)

  • Management of complications (acute HF)

  • Management of complications (DIC)

  • Management of complications (CNS manifestations)

  • Management of complications (gastrointestinal)

Therapeutic procedures

Plasmapheresis: as per JES/JTA 2016 guidelines, consider performing therapeutic plasma exchange if clinical improvement is not noted within 24-48 hours of initial treatment with appropriate doses of antithyroid drugs, inorganic iodine, corticosteroids, or β-blockers, as well as specific treatment for the triggering disease and complications with thyroid storm.
C

Preventative measures

Prevention
As per JES/JTA 2016 guidelines:
Take care to prevent thyroid storm in patients with poor adherence undergoing antithyroid drug treatment.
B
Consider offering definitive treatment of Graves' disease, either by radioactive iodine or thyroidectomy, to prevent recurrent thyroid storm in patients successfully managed during the acute stage of thyroid storm.
B