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endo.thyroid-storm.core.v1PRODUCTION
endo.thyroid-storm.core.v1

Thyroid storm

endocrinologyacuteadultpregnancy
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Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Recognize storm pattern (BWPS ≥45 or JTA criteria) in thyrotoxic patient; impending storm 25-44 still requires aggressive therapy

Inputs
2
Actions
0
Advance rule
Set
Advance when

storm threshold crossed by BWPS or clinical gestalt

Patient inputs (11)

Elderly + apathetic storm presentation; pregnancy alters drug choice (PTU 1st trimester)

Etiology drives long-term plan (RAI vs surgery)

1st trimester PTU > methimazole; MFM + neonatology

Suppressed TSH essential

Markedly elevated; correlates with severity

T3 toxicosis subset; PTU blocks T4→T3 conversion

Hyperpyrexia drives BWPS; cooling intervention

Tachycardia / AF drives β-blocker selection

Shock + HF complication of storm; affects esmolol vs propranolol choice

Amiodarone, recent iodinated contrast (precipitates AIT/Jod-Basedow), checkpoint inhibitor

Hepatic dysfunction is BWPS criterion; PTU hepatotoxicity baseline

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (7)

7 need judgement
  • informationallife_threateningBWPS_ge_45_storm
    Burch-Wartofsky Point Scale ≥45 (Burch-Wartofsky 1993)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningpregnancy_storm_first_trimester
    Thyroid storm in first trimester (ATA 2016 Ross)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningagranulocytosis_thionamide
    ANC <500 on PTU or methimazole (ATA 2016 Ross)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereBWPS_25_to_44_impending
    BWPS 25-44 (impending storm) (Burch-Wartofsky 1993)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverestorm_with_HF_use_esmolol
    Storm with HF or borderline hemodynamics (JES 2016)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverePTU_hepatotoxicity
    ALT >3x ULN on PTU (ATA 2016 Ross)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereiodine_load_jod_basedow
    Storm precipitated by iodinated contrast or amiodarone (ATA 2016 Ross)
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

Thyroid storm — 5-pillar (block synthesis → block release → block periphery → cool → support)
axis: thyroid_storm_5pillarstep 1 - Pillar 1 — Block hormone synthesis (thionamide FIRST)
Selected step "Pillar 1 — Block hormone synthesis (thionamide FIRST)" — Storm criteria met (BWPS ≥45 or JTA TS1/TS2 or clinical gestalt)
  • propylthiouracil
    first line
    thionamide
    500–1000 mg PO/NG load → 250 mg PO/NG q4h • PO/NG • q4h
    triggers: storm_confirmed, first_trimester_pregnancy, methimazole_intolerant
    ATA 2016 — preferred in storm because also blocks T4→T3 peripheral conversion; 1st trimester pregnancy preferred over methimazole (teratogenicity); switch to methimazole after storm resolves due to PTU hepatotoxicity
    rxcui 8794
  • methimazole
    first line
    thionamide
    60–80 mg/day in divided doses (e.g., 20 mg PO q6h) • PO/NG • q6–8h
    triggers: storm_confirmed, second_or_third_trimester, PTU_unavailable_or_hepatotoxicity
    ATA 2016 — alternative; preferred long-term (less hepatotoxic); does NOT block T4→T3 conversion
    rxcui 6835

ed playbook — drug actions (6)

  1. 1. propylthiouracil (or methimazole)
    PTU 500–1000 mg PO/NG load; methimazole 60–80 mg PO/NG • PO/NG • load now
    trigger: Storm criteria met
    Block synthesis FIRST
  2. 2. propranolol or esmolol
    Propranolol 0.5–1 mg IV slow push titrated to 5–10 mg, OR esmolol 500 mcg/kg bolus then 50 mcg/kg/min • IV • titrated
    trigger: HR >130 or hyperadrenergic
    Adrenergic block + peripheral conversion
  3. 3. hydrocortisone
    300 mg IV bolus • IV • STAT
    trigger: Storm
    Block T4→T3 + cover AI
  4. 4. iodine (SSKI)
    5 drops PO q6h, GIVEN ≥1h AFTER thionamide • PO/NG • q6h starting 1h after PTU/MMI
    trigger: After thionamide
    Wolff-Chaikoff
  5. 5. acetaminophen
    1000 mg IV/PO • IV/PO • q6h
    trigger: Fever
    NEVER aspirin
  6. 6. cooling measures
    Ice packs to groin/axillae, cooling blanket • physical • continuous
    trigger: Temp >39°C
    Active cooling

Auto-drafted A&P note

ed

Subjective

- Possible entry pathways: Hyperpyrexia + sinus tach/AF + AMS; Suppressed TSH + markedly elevated FT4/FT3; Known Graves with infection / surgery / iodine load.

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Thyroid storm** (endo.thyroid-storm.core.v1).
Phenotype framing: Phenotype: Graves decompensated, toxic nodular goiter, amiodarone-induced (type 1 vs 2), factitious thyrotoxicosis, postpartum thyroiditis storm; rule out sepsis / NMS / serotonin syndrome / pheo
Scope: Recognize storm pattern (BWPS ≥45 or JTA criteria) in thyrotoxic patient; impending storm 25-44 still requires aggressive therapy

No severity triggers fired against current inputs.

Plan

Regimen axis: **Thyroid storm — 5-pillar (block synthesis → block release → block periphery → cool → support)** — step "Pillar 1 — Block hormone synthesis (thionamide FIRST)".
1. propylthiouracil 500–1000 mg PO/NG load → 250 mg PO/NG q4h PO/NG q4h (thionamide, first line) — ATA 2016 — preferred in storm because also blocks T4→T3 peripheral conversion; 1st trimester pregnancy preferred over methimazole (teratogenicity); switch to methimazole after storm resolves due to PTU hepatotoxicity
2. methimazole 60–80 mg/day in divided doses (e.g., 20 mg PO q6h) PO/NG q6–8h (thionamide, first line) — ATA 2016 — alternative; preferred long-term (less hepatotoxic); does NOT block T4→T3 conversion

Setting playbook (ed) — Recognize storm, start 5-pillar bundle in correct sequence, transfer to ICU
3. propylthiouracil (or methimazole) PTU 500–1000 mg PO/NG load; methimazole 60–80 mg PO/NG PO/NG load now — Storm criteria met (Block synthesis FIRST)
4. propranolol or esmolol Propranolol 0.5–1 mg IV slow push titrated to 5–10 mg, OR esmolol 500 mcg/kg bolus then 50 mcg/kg/min IV titrated — HR >130 or hyperadrenergic (Adrenergic block + peripheral conversion)
5. hydrocortisone 300 mg IV bolus IV STAT — Storm (Block T4→T3 + cover AI)
6. iodine (SSKI) 5 drops PO q6h, GIVEN ≥1h AFTER thionamide PO/NG q6h starting 1h after PTU/MMI — After thionamide (Wolff-Chaikoff)
7. acetaminophen 1000 mg IV/PO IV/PO q6h — Fever (NEVER aspirin)
8. cooling measures Ice packs to groin/axillae, cooling blanket physical continuous — Temp >39°C (Active cooling)

Non-pharmacologic actions:
- Continuous cardiac monitor
- IV access × 2
- Foley + strict I/Os
- NG tube if NPO/AMS for thionamide administration (no IV thionamide in US)
- Treat precipitant (sepsis bundle, withdraw amiodarone if AIT)

AVOID / contraindication checks:
- Never iodine before thionamide (JES 2016; Burch Wartofsky 1993)
- Avoid aspirin in storm (ATA 2016 Ross)
- Propranolol caution severe HF use esmolol (JES 2016)
- PTU first trimester methimazole 2nd 3rd trimester (ATA 2016 Ross)
- PTU hepatotoxicity baseline LFT then q weekly (ATA 2016 Ross)
- Agranulocytosis warning PTU MMI baseline CBC (ATA 2016 Ross)
- Check QTc with propranolol dofetilide amiodarone combo (NICE 2019)

Monitoring

Regimen monitoring:
- continuous telemetry (JES 2016)
- q1h vitals and temp (Burch-Wartofsky 1993)
- BWPS q12h reassessment (Burch-Wartofsky 1993)
- TSH FT4 FT3 q24-48h (ATA 2016 Ross)
- CBC q weekly for agranulocytosis (ATA 2016 Ross)
- LFT baseline then q weekly on PTU (ATA 2016 Ross)
- QTc on ECG if concurrent QT-prolonging agents (NICE 2019)

Setting (ed) monitoring:
- HR + temp q15 min initially (Burch-Wartofsky 1993)
- BP + GCS continuous (JES 2016)
- BMP + LFT + CBC at baseline (ATA 2016 Ross)

Follow-up plan: Endocrinology + thyroid ultrasound; plan definitive therapy (RAI or thyroidectomy after 4-8 wk antithyroid stabilization); ophthalmopathy assessment; agranulocytosis education
- Close-out criterion: definitive therapy plan + follow-up scheduled

Monitoring phase: Continuous telemetry, q1h vitals + temp, q24-48h TSH/FT4/FT3, q-weekly CBC for agranulocytosis on PTU/MMI, daily LFT for PTU hepatotoxicity, QTc on ECG

Disposition

Current setting: ed — Recognize storm, start 5-pillar bundle in correct sequence, transfer to ICU

Disposition criteria:
- ICU mandatory for all confirmed storm (JES 2016)
- Ward only after BWPS <25, AF rate-controlled, HC tapering, on PO thionamide (Burch-Wartofsky 1993)

Escalation triggers (move to higher acuity):
- AMS / coma → ICU + airway watch (JES 2016)
- HF / cardiogenic shock → ICU + esmolol switch (JES 2016)
- Refractory hyperthermia despite cooling → ICU + neuromuscular paralysis (JES 2016)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Burch-Wartofsky Point Scale ≥45 (Burch-Wartofsky 1993)
- [LIFE_THREATENING] Thyroid storm in first trimester (ATA 2016 Ross)
- [LIFE_THREATENING] ANC <500 on PTU or methimazole (ATA 2016 Ross)

Citations

- 2016 ATA Hyperthyroidism Guideline + 2016 JTA/JES Thyroid Storm Guidelines + 2023 ETA Hyperthyroidism + Burch-Wartofsky 1993 [PMID:22690898](https://pubmed.ncbi.nlm.nih.gov/22690898/)
- Cited evidence (PMID 27521067) [PMID:27521067](https://pubmed.ncbi.nlm.nih.gov/27521067/)

Last reconciled with current guidelines: 2026-05-22.
References
  • 2016 ATA Hyperthyroidism Guideline + 2016 JTA/JES Thyroid Storm Guidelines + 2023 ETA Hyperthyroidism + Burch-Wartofsky 1993 — PMID:22690898
  • Cited evidence (PMID 27521067) — PMID:27521067