Approach to the patient with thyroid storm

Thyroid storm, or thyrotoxic crisis, is a rare but life-threatening hypermetabolic state arising from severe thyrotoxicosis with a high risk of multiorgan failure. It typically occurs in individuals with untreated or poorly controlled hyperthyroidism, most often Graves' disease, though various other disorders may also precipitate it. Common triggers include infection, surgery, trauma, abrupt discontinuation of antithyroid medication, severe emotional or physical stress, and iodine exposure. Clinical manifestations involve hyperthermia, tachyarrhythmia, cardiac and respiratory failure, and hepatic dysfunction. Neurological and gastrointestinal symptoms, such as agitation, confusion, delirium, vomiting, diarrhea, and profuse sweating, are frequent. Diagnosis is clinical rather than biochemical, and scoring systems are used to support the diagnosis. Thyroid storm is more common in females, with an incidence of approximately 0.2 to 1.1 per 100 000 in the general population and 4.8 to 6.3 per 100 000 among hospitalized patients. Without rapid intervention, mortality remains high (5 to 25%), primarily due to cardiovascular collapse or multiorgan dysfunction. Management requires immediate supportive therapy, including cardiovascular stabilization, respiratory support, and temperature control, along with identification and treatment of precipitating factors. Pharmacologic therapy involves antithyroid agents to block thyroid hormone synthesis, beta blockers to counteract adrenergic effects, corticosteroids to reduce peripheral conversion and support adrenal function, and, when appropriate, iodine administration after thionamides. Early recognition and intensive management are crucial to prevent fatal outcomes, highlighting the need for vigilance in patients with severe thyrotoxicosis or decompensated hyperthyroidism.