CCM Notes
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Endocrinology · Critical Care
Thyroid Storm
Burch-Wartofsky Score · PTU / Methimazole · Beta-Blockade · Iodine Therapy · Supportive Care
📊 Burch-Wartofsky Point Scale (BWPS) — Diagnosis
Temperature (°C)
37.2–37.75
37.8–38.310
38.3–38.815
38.9–39.420
39.4–39.925
≥40.030
CNS Effects
Absent0
Mild (agitation)10
Moderate (delirium)20
Severe (seizure, coma)30
GI-Hepatic
Absent0
Moderate (N/V/D)10
Severe (jaundice)20
Cardiovascular
HR 100–1095
HR 110–11910
HR 120–12915
HR 130–13920
HR ≥14025
AF+10
CHF (mild/mod/sev)5/10/15
Precipitant
Positive+10
≥45
Thyroid storm — treat immediately
💊 Treatment Sequence — MUST Follow This Order (ATA 2016)
1
Thionamide (PTU preferred)
PTU 500–1000 mg loading, then 250 mg q4h PO/NG
Blocks new hormone synthesis + blocks T4→T3 conversion. Give FIRST before iodine.
2
Iodine (≥1h after PTU)
SSKI 5 drops q6h PO
or Lugol's 10 drops q8h PO
Wolff-Chaikoff effect — blocks thyroid hormone release. NEVER give before PTU.
3
Beta-Blocker
Propranolol 60–80 mg PO q4–6h
or IV 0.5–1 mg slow bolus
Controls adrenergic symptoms + blocks T4→T3 conversion. Titrate to HR <100 bpm.
4
Glucocorticoids
Hydrocortisone 100 mg IV q8h
or Dexamethasone 2 mg IV q6h
Blocks T4→T3; prevents relative adrenal insufficiency. Continue until improving.
🔥 Precipitants to Identify & Treat
Infection (most common) — blood/urine cultures; empiric antibiotics
Surgery / trauma
Iodine load (contrast dye, amiodarone)
Radioiodine therapy (thyroid release)
Cessation of antithyroid medications
Pregnancy / parturition
Palpation/biopsy of thyroid gland
Emotional stress, vigorous exercise
🏥 Supportive Care (ICU Required)
Cooling blankets; antipyretics (Acetaminophen — NOT aspirin; aspirin displaces T4 from TBG)
IV fluids; glucose-containing solutions (avoid dehydration)
Correct hyperglycemia with insulin protocol
Cardiac monitoring for AF → rate control with propranolol
Cholestyramine 4g PO QID: binds thyroid hormones in gut (adjunctive)
Plasmapheresis: refractory cases unresponsive to standard therapy
Methimazole alternative to PTU if liver disease exists (PTU can cause hepatitis)
⚠️ Critical Reminders
●Never give iodine BEFORE thionamide — will worsen thyroid storm (Wolff-Chaikoff failure)
●Do NOT use aspirin for fever — displaces T4 from thyroid-binding globulin → worsens thyrotoxicosis
●Mortality: 10–20% even with treatment. ICU admission mandatory for BWPS ≥45
●Methimazole is preferred for non-urgent hyperthyroidism; PTU preferred in thyroid storm + pregnancy (1st trimester)