Thyroid Storm — Management Pathway

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

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Full pathway

1. [Decision] Does it suggest thyroid storm?
   What does the Burch-Wartofsky score suggest? (Life-threatening thyrotoxicosis. Burch-Wartofsky (temperature, CNS, GI-hepatic, heart rate, heart failure, AF, precipitant): ≥45 suggests storm, 25–44 impending, <25 unlikely. Common precipitants: infection, surgery, drug withdrawal, iodinated contrast, DKA.)
   • Storm / impending (≥25) → Storm → quartet + support
   • Severe thyrotoxicosis only (<25) → Severe thyrotoxicosis (not storm)
2. [End] Severe thyrotoxicosis (not storm)
   Beta-blocker for symptom control, thionamide antithyroid drug, find and treat the precipitant, monitor closely; watch for progression to storm and escalate to the storm regimen once criteria are met.
3. [End] Storm → quartet + support
   ICU, multi-pronged: 1) Beta-blocker (propranolol 60–80 mg PO q4–6h or IV — controls rate, inhibits T4→T3; use esmolol for heart failure / when titration is needed). 2) Thionamide (PTU 500–1000 mg loading then 250 mg q4h, preferred — also blocks peripheral conversion; or methimazole 20–25 mg q4–6h). 3) Iodine (SSKI/Lugol, given ≥1 h after the thionamide to block release — never before the thionamide or it worsens). 4) Glucocorticoid (hydrocortisone 100 mg IV q8h, inhibits conversion + adrenal support). 5) Support: cooling (acetaminophen, not aspirin — raises free T4/T3), fluids, treat the precipitant.

Source guidelines & references

• Burch HB, Wartofsky L. Life-threatening thyrotoxicosis · thyroid storm. Endocrinol Metab Clin North Am 1993
• Japan Thyroid Association guideline for thyroid storm

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

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