Signs and urgent management of thyroid storm in the perioperative period?

• A. Hyperthermia, tachycardia, hypertension, agitation; treat with methimazole or PTU, iodine, beta-blockade (esmolol), cooling, aggressive IV fluids.
• B. Hypothermia and bradycardia; give thyroid hormone.
• C. Hypotension treated with pressors only.
• D. No specific therapy; observation.

Answer: (A)

Thyroid storm is an acute, life-threatening surge of thyroid hormone effects, often precipitated by surgery or infection in the perioperative period. The key signs reflect a hypermetabolic state: high fever, rapid heart rate, high blood pressure, agitation or delirium, sweating, and tremor. The urgent management aims to rapidly lower thyroid hormone production and release, block the effects of already circulating hormone, and treat the resulting hypermetabolic and hemodynamic stress.

Start antithyroid therapy with methimazole or propylthiouracil to block new hormone synthesis; PTU is often preferred in storm because it also decreases peripheral conversion of T4 to T3. Then give iodine after thioamides to inhibit release of stored hormone. Use a short-acting beta-blocker such as esmolol to control tachycardia and reduce sympathetic overactivity. Aggressive cooling and intravenous fluids are essential to treat hyperthermia and maintain circulation, and hydrocortisone can be considered to address potential adrenal insufficiency and further limit T4 to T3 conversion. Continuous monitoring and support for airway, ventilation, electrolytes, and organ perfusion are critical.

Options describing hypothermia with bradycardia, or proposing thyroid hormone administration, or advocating only observation, don’t fit thyroid storm and would fail to address the underlying crisis.