Thyroid Storm Medical Slides

Present the BWPS components with point values: Temperature (5 pts per 0.5°C above 37.2°C, max 30), CNS effects (10-30: agitation → delirium → seizure/coma), GI-hepatic (10-20: diarrhea → jaundice), Heart rate (5-25: 100-109 to ≥140), Heart failure (5-15: mild → severe/pulmonary edema), Atrial fibrillation (10 points). Score interpretation: ≥45 = highly suggestive of thyroid storm, 25-44 = impending storm, <25 = unlikely storm. Key teaching point: BWPS is a clinical scoring system — do NOT wait for thyroid function test results to initiate treatment. TSH and free T4/T3 levels are identical in thyroid storm vs uncomplicated thyrotoxicosis; the distinction is clinical severity.

Present the time-sensitive sequence with rationale: (1) PTU 500-1000 mg loading dose PO/NG (or methimazole 60-80 mg if PTU unavailable) — blocks new hormone synthesis AND (PTU only) blocks peripheral T4→T3 conversion. (2) Iodine (SSKI 5 drops q6h or Lugol 10 drops q8h) — given ≥1 HOUR after thionamide (otherwise iodine provides substrate for new hormone synthesis, Wolff-Chaikoff effect is temporary). (3) Propranolol 60-80 mg PO q4-6h or esmolol drip (controls adrenergic symptoms + blocks T4→T3 conversion at high doses). (4) Hydrocortisone 100 mg IV q8h — blocks T4→T3 conversion, treats relative adrenal insufficiency, prevents adrenal crisis. This four-drug protocol addresses synthesis, release, conversion, and end-organ effects.

Present rescue therapies for patients not responding to standard protocol within 24-48 hours: Plasmapheresis (plasma exchange) — directly removes circulating thyroid hormones and protein-bound hormone; typically produces rapid clinical improvement. Used as bridge to definitive therapy (thyroidectomy). Usually 1-3 sessions needed. Cholestyramine 4 g PO QID — binds thyroid hormones in the enterohepatic circulation, reduces T4 levels by 20-30%. Lithium carbonate 300 mg PO TID — blocks thyroid hormone release (used when iodine is contraindicated, e.g., iodine allergy). Emergency thyroidectomy — definitive treatment in truly refractory cases, but high perioperative risk; medical optimization for 24-48 hours preferred when possible.