This handout is for thyroid storm with htn-emergency overlap (bwps ≥45 + afib-rvr + hf + ams). Your care team identified this based on: hyperthermia (>38.5) + tachyarrhythmia (hr >130 or afib-rvr) + htn crisis + hf signs + ams in known/suspected hyperthyroid patient (burch-wartofsky ≥45 — burch & wartofsky 1993 pmid 8325286).
Other reasons your team may use this plan: graves disease or toxic multinodular goiter + recent precipitant (infection, surgery, contrast load, rai, parturition, trauma, dka) + new severe htn; tsh <0.01 + free t4 + free t3 markedly elevated + clinical pentad — biochemical confirmation of thyroid storm; afib with rvr + new hf + severe htn + hyperthermia + tremor + diarrhea — high-output cardiac failure pattern with htn overlap.
Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.
| Medication | Starting dose | How | When | What it does |
|---|---|---|---|---|
| propranolol | 1-2 mg IV q15 min titrate to HR <100 + BP control; transition to 60-80 mg PO q4h once tolerated | IV then PO | q15 min IV / q4h PO | ATA 2016 PMID 27521067 — non-selective BB preferred (also blocks peripheral T4→T3 conversion); blunts adrenergic surge driving HTN + AFib + tremor + hyperthermia |
| esmolol | 500 mcg/kg IV bolus over 1 min, then 50-300 mcg/kg/min infusion titrate | IV | continuous | ATA 2016 — short half-life (~9 min) allows rapid titration + reversibility if HF/asthma intolerance; preferred in unstable patients |
| PTU (propylthiouracil) | 500-1000 mg PO/NG/PR loading dose, then 200-250 mg q4h | PO/NG/PR | q4h | ATA 2016 PMID 27521067 — PTU PREFERRED in storm (additional peripheral T4→T3 conversion block via D1 deiodinase inhibition); methimazole superior outside storm but PTU rapid block essential here; monitor LFT for hepatotox |
| methimazole | 60-80 mg PO/NG load, then 30-40 mg q6h | PO/NG | q6h | ATA 2016 — alternative when PTU intolerant; less hepatotox, longer half-life; lacks T4→T3 block but acceptable when transitioning out of storm |
| potassium iodide (Lugol) | 5 drops (250 mg) PO q8h — START ≥1 h AFTER first thionamide dose | PO | q8h | ATA 2016 PMID 27521067 — Wolff-Chaikoff effect blocks hormone release; CRITICAL TIMING: must follow thionamide ≥1 h to avoid substrate loading worsening storm |
| hydrocortisone | 300 mg IV load, then 100 mg IV q8h | IV | q8h | ATA 2016 — blocks T4→T3 conversion + covers relative adrenal insufficiency (catechol-mediated cortisol consumption); empiric for any storm |
| cholestyramine | 4 g PO QID | PO | QID | Binds enterohepatic T4 circulation → reduces serum hormone; useful adjunct in severe storm or PTU-intolerant; ATA 2016 mention |
| nicardipine | 5 mg/h IV titrate by 2.5 mg/h q5-15 min, max 15 mg/h | IV | continuous | Adjunct for refractory HTN after maximal BB; CCB acceptable in storm but less data; AVOID non-DHP CCB (verapamil/diltiazem) if HF |
| acetaminophen | 650-1000 mg PO/PR q4-6h | PO/PR | q4-6h | ATA 2016 — acetaminophen for hyperthermia (NOT ASA — displaces T4 from TBG); aggressive cooling priority |
| AVOID aspirin (ASA) | AVOID | N/A | N/A | ATA 2016 PMID 27521067 — ASA displaces T4 from thyroxine-binding globulin (TBG) → increases FREE thyroid hormone → worsens storm; absolute contraindication for fever |
| AVOID amiodarone | AVOID | N/A | N/A | Amiodarone is iodine-rich → worsens hyperthyroidism (~37% iodine by weight); use BB for rate control + cardioversion if needed; lidocaine acceptable if VT |
| AVOID over-aggressive cooling causing shivering | AVOID shivering response | N/A | N/A | Shivering generates catecholamine surge worsening HTN + tachy + heat production; sedate (benzodiazepines) + cool with evaporation/cooling blankets at controlled rate |
| Plasmapheresis if refractory | Per nephrology / apheresis service | extracorporeal | as needed | ATA 2016 — plasmapheresis can rapidly reduce circulating thyroid hormone in refractory storm; bridge to definitive thyroidectomy |
Plan: Thyroid storm with HTN-emergency overlap — sequenced cascade: BB FIRST → THIONAMIDE → IODINE ≥1 h after → HYDROCORTISONE → CHOLESTYRAMINE; AVOID ASA + amiodarone
Contact your care team if any of the following happen:
Call 911 or go to the nearest emergency room right away if you have:
Definitive thyroid therapy when euthyroid (4-6 wk) — RAI ablation OR thyroidectomy (surgery preferred if compressive goiter, suspicious nodule, severe ophthalmopathy, pregnancy plans, or RAI failure); lifelong levothyroxine post-definitive; endocrinology long-term; AVOID future precipitants (educate); MedicAlert; family screening for autoimmune thyroid
Guideline: ATA 2016 Hyperthyroidism / Thyrotoxicosis Management (Ross Thyroid PMID 27521067) + Burch-Wartofsky 1993 (PMID 8325286) + 2025 ACC/AHA HTN (Whelton)