Evidence-
Based Practice
Thyroid Storm
hyroid storm, also known as a severe state of thy-
T rotoxicosis, is an intense metabolic imbalance
that can be fatal without prompt diagnosis and
treatment (Czako, 2015; Schraga 2016). In 1931, Dr. F.H.
Lahey (1931) differentiated manifestations of typical
hyperthyroidism from the severity of what later became
known as thyroid storm. The thyroid gland becomes
over-stimulated and produces an excess of thyroid hor-
mones, leading to an extreme hyperthyroid state
(Czako, 2015; Franklyn & Boelaert, 2012). Associated
mortality rate is 10%-30% for patients receiving treat-
ment for this condition (Czako, 2015). Without treat-
ment, mortality can climb to 90% (Madhusmita, 2016).
A brief review is provided of normal thyroid function, as
well as a description of the hyperthyroid state and man-
ifestations leading to thyroid storm. Diagnostics, treat-
ment strategies, and nursing management considera-
tions are explored.
Normal Thyroid Function
The butterfly-shaped thyroid gland is located in the
neck, posterior to the larynx and immediately inferior
to the cricoid cartilage. The two lobes of this endocrine
gland are positioned over the anterior trachea. They are
linked by the isthmus, a bridge of narrow tissue
(Crawford & Harris, 2013; Mag, 2013).
The thyroid gland produces the hormones
triiodothyronine (T3), thyroxine (T4), and calcitonin.
Dietary intake of iodine and protein is required for the
production of these hormones (Crawford & Harris,
2013; Leung, 2016). The thyroid is involved in body
temperature regulation as well as energy production and
metabolism (Mag, 2013). Feedback mechanisms among
the thyroid gland, hypothalamus, and pituitary gland
drive normal thyroid functioning. Secretion of thy-
rotropin-releasing hormone (TRH) by the hypothala-
mus controls the release of thyroid-stimulating hor-
mone (TSH) by the pituitary gland, which controls the
release of T3 and T4 from the thyroid. Most T3 (80%-
90%) comes from T4 conversion to T3 in the peripheral
circulation (Leung, 2016).
Also produced by the thyroid gland, calcitonin has
two major roles in the body. This hormone reduces
tubular uptake of calcium and phosphate in the renal
Mary L. Schreiber, MSN, RN, CMSRN®, is Nursing Faculty Member,
Orangeburg-Calhoun Technical College, Orangeburg, SC, and a
national speaker for PESI Healthcare.
March-April 2017 • Vol. 26/No. 2
Mary L. Schreiber
system and reduces bone resorption, causing less calci-
um to be released into the blood. The amount of calci-
tonin secreted by the thyroid gland is driven by the
level of calcium in the blood (Crawford & Harris, 2013).
Etiologies of Thyroid Storm
Thyroid storm occurs infrequently (Chiha,
Samarasinghe, & Kabaker, 2015; Schraga, 2016). It is
more common in persons ages 30-40 and occurs more
in females than males (Madhusmita, 2016; Mag, 2013).
In the United States, hyperthyroidism is seen more fre-
quently in Caucasians and Hispanics than African
Americans (Schraga, 2016). Numerous conditions and
stressors can precipitate this extreme hyperthyroid state.
The goal is to recognize the manifestations and initiate
treatment while also working to identify the underlying
trigger. The most common cause of thyroid storm is a
medical history of Grave’s disease (Czako, 2015). Grave’s
disease is an autoimmune disease wherein autoantibod-
ies affect TSH stimulation, resulting in excessive produc-
tion of T3 and T4 (Franklyn & Boelaert, 2012). In the
patient with pre-existing hyperthyroidism, poor med-
ication management by a provider or nonadherence by
the patient can increase risk for thyroid storm. Thyroid
storm also can occur in the patient who does not have
a pre-existing hyperthyroid condition (Chiha et al.,
2015). See Table 1 for various reported etiologies of this
condition.
Clinical Features and Diagnostics
Factors supporting diagnosis and management of
thyroid storm include the patient’s medical history and
serum thyroid hormone values (commonly elevated T3
and T4 with suppressed TSH) (Chiha et al., 2015;
Crawford & Harris, 2013; Franklyn & Boelaert, 2012).
Rarely, TSH can be elevated due to excess secretion
(Madhusmita, 2016). Table 2 includes common clinical
features of this hypermetabolic state. However, the older
adult patient may present with atypical symptoms (apa-
thetic thyroid storm) (Akamizu et al., 2012).
The diverse, severely exaggerated symptoms of
hyperthyroidism, coupled with abnormal serum thyroid
values, substantiate the thyroid storm diagnosis (Chiha
et al., 2015; Leung, 2016). Additional serum studies
include calcium, glucose, blood urea nitrogen, liver
function, and complete blood count. High bone resorp-
tion can result in hypercalcemia. Hyperglycemia is more
likely to occur than hypoglycemia. Leukocytosis may
indicate infection (Chiha et al., 2015; Crawford &
143
Evidence-Based Practice
TABLE 1.
Etiologies of Thyroid Storm
• Grave’s disease
• Infection
• Stress
• Trauma
• Surgery (thyroid and non-thyroid)
• Thyroid tumor/nodules/goiter
• Genetics
• Medications or withdrawal/interruption of regime
• Contrast dye (in radiologic studies)
• Excessive thyroid palpation or manipulation
• Hydatidiform mole (molar pregnancy)
• Myocardial infarction
• Hypoglycemia or diabetic ketoacidosis
Sources: Chiha et al., 2015; Crawford & Harris, 2013; Czako,
2015; Franklin & Boelaert, 2012; Leung, 2016; Mag, 2013
TABLE 2.
Clinical Presentation of Thyroid Storm
• Hypermetabolic state
• Hyperpyrexia (>104o F)
• Tachycardia (>130 bpm)
• Palpitations/arrhythmia
• Hypertension (with increased pulse pressure)
• Hypotension (if shock develops)
• Heat intolerance
• Diaphoresis
• Dehydration
• Abnormal laboratory values
• Dyspnea
• Restlessness/irritability
• Mental status change, delirium, stupor, coma
• Nausea/vomiting/diarrhea
• Multiple organ failure
Sources: Akamizu et al. 2012; Chiha et al., 2015; Leung,
2016; Madhusmita, 2016; Mag, 2013
Harris, 2013). Agranulocytosis and leukopenia also are
possible. A radioactive iodine uptake study (via thyroid
scan), ultrasound, and aspirate biopsy can be additional
diagnostic choices (Chiha et al., 2015; Crawford &
Harris, 2013).
Scoring systems also can contribute to a thyroid
storm diagnosis. The Burch-Wartofsky system uses a
numeric score determined by specific criteria related to
the patient’s history of precipitants and body systems
dysfunction: central nervous, gastrointestinal, and car-
diovascular systems (heart rate, presence of atrial fibril-
lation and/or heart failure) as well as thermoregulation
(Chiha et al., 2015; Leung, 2016; Madhusmita, 2016).
The Akamizu criteria, derived from the largest case study
of thyroid storm, considers the presence of various sys-
tems manifestations instead of assigning a score
(Akamizu et al., 2012; Chiha et al., 2015). Serum labora-
tory studies, use of scoring systems, and other diagnos-
tics can provide additional assessment value; however,
144
TABLE 3.
Essential Treatment Strategies and Nursing
Management for Thyroid Storm
• Vital signs assessment
• Body systems assessment
• Bleeding signs (e.g., continual swallowing)
• Cardiac monitoring
• Glucose monitoring
• Medication administration
◆ Thionamides
■ Propylthiouracil (PTU) (effective, but severe risk
for hepatic injury)
■ Methimazole
◆ Anti-adrenergics
■ Beta-blockers
■ Calcium channel blockers (if beta-blockers
contraindicated)
◆ Glucocorticoids
■ Hydrocortisone
■ Dexamethasone
◆ Iodine compounds
■ Potassium iodide
◆ Antipyretics
■ Acetaminophen
• Mental status assessment
• Cooling methods (e.g., cooling blanket, ice packs, alco-
hol sponges, environment temperature)
• Intravenous fluid replacement
• Electrolytes/glucose replacement
• Oxygen administration (possible ventilator support)
• Serum laboratory values monitoring
• Intake/output measurement
• High-calorie, high-protein diet (related to metabolic
needs)
• Daily weights
• Close interprofessional communication
• Safety precautions
• Patient education
Sources: Chiha et al., 2015; Crawford & Harris, 2013; Leung,
2016; Madhusmita, 2016
awaiting the results should not delay the clinician’s deci-
sion for rapid patient treatment (Chiha et al., 2015;
Crawford & Harris, 2013; Madhusmita, 2016). Even
when death is averted, irreversible organ damage can
arise from thyroid storm (Chiha et al., 2015).
Treatment Strategies and Nursing
Management
Treatment must be initiated immediately. Aggressive
treatment and fastidious patient monitoring are essen-
tial and should be performed in the critical care envi-
ronment. Close, consistent assessment is critical due to
the disorder’s multi-system involvement. Nurses also
must recognize the sensitivity of serum thyroid values
to numerous medications and unrelated thyroid condi-
tions. Laboratory values must be monitored, and ongo-
ing communication within the interprofessional team is
essential for optimal outcomes (Chiha et al., 2015;
March-April 2017 • Vol. 26/No. 2
 Thyroid Storm

REFERENCES
Leung, 2016). See Table 3 for essential treatment strate-
Akamizu, T., Satoh, T., Isozaki, O., Suzuki, A., Wakino, S., Iburi, T., …
gies related to thyroid storm.
Mori, M. (2012). Diagnostic criteria, clinical features, and incidence
A usual medication regimen includes thionamides,
of thyroid storm based on nationwide surveys. Thyroid, 22(7), 661-
679. doi:10.1089/thy.2011.0334.
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Chiha, M., Samarasinghe, S., & Kabaker, A.S. (2015). Thyroid storm: An
and antipyretics (Crawford & Harris, 2013;
updated review. Journal of Intensive Care Medicine, 30(3), 131-140.
Madhusmita, 2016). Thionamides stop production of
Crawford, A., & Harris, H. (2013). Tipping the scales: Understanding thy-
thyroid hormones. Adrenergic blockade (beta-blockers)
reduces sympathetic nervous system effects and decreas- roid imbalances. Nursing 2013 Critical Care, 8(1), 23-28.
Czako, P.F. (2015). Thyrotoxic storm following thyroidectomy. Retrieved
from http://emedicine.medscape.com/article/850924-overview
es oxygen needs in the hypermetabolic state (Chiha et

Franklyn, J.A., & Boelaert, K. (2012). Thyrotoxicosis. Lancet, 379(9821),

al., 2015). When beta-blockers are contraindicated, cal-
1155-1166.
cium channel blockers are used. Glucocorticoids are
Lahey, F.H. (1931). Apathetic thyroidism. Annals of Surgery, 93(5), 1026-
effective in reducing T4 conversion to T3, aiding in pre-
1030.
Leung, A.M. (2016). Thyroid emergencies. Journal of Infusion Nursing,
vention of adrenal insufficiency, and calming vasomo-

tor symptoms. Iodine compounds obstruct secretion of
thyroid hormones, reducing serum values (Crawford &
Harris, 2013; Madhusmita, 2016). Antipyretics work to
reduce fever, with acetaminophen being recommended
over aspirin. Aspirin causes interference with T4 protein
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Madhusmita, M. (2016). Thyroid storm. Retrieved from http://emedicine.
medscape.com/article/925147-overview#showall
Mag, J. (2013). Hyperthyroidism nursing management. Retrieved from
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Schraga, E.D. (2016). Hyperthyroidism, thyroid storm, and Grave’s dis-

binding, resulting in serum increases of free T3 and T4
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(Crawford & Harris, 2013).
767130-overview#showall
Continuous cardiac monitoring is important related
to risk for arrhythmia, most commonly atrial fibrillation
(Madhusmita, 2016). Suction should be available at the
bedside and a tracheostomy set accessible in case of air-
way obstruction (Mag, 2013). When thyroid storm is
recognized early, appropriate treatment can be provided
promptly and the patient’s condition should progress
positively within 24-48 hours (Chiha et al., 2015;
Madhusmita, 2016).
Nonadherence to the treatment regimen is the lead-
ing reason for failure (Franklyn & Boelaert, 2012). The
nurse must provide education to the patient and care-
giver regarding prescribed medications and the impor-
tance of consistently following the regimen (Akamizu et
al., 2012). The nurse also should help the patient under-
stand the importance of keeping regular follow-up
appointments and monitoring serum thyroid hormones
(Crawford & Harris, 2013; Franklyn & Boelaert, 2012).
Soy, cheddar cheese, mayonnaise, seafood, and high-
iodine foods should not be consumed (Crawford &
Harris, 2013). Stimulants also should be avoided: caf-
feine, sugary foods and drinks, sodas, and energy bars.
The patient should not smoke (Mag, 2013).

Conclusion
Thyroid storm is an endocrine system emergency
(Madhusmita, 2016). The need for rapid response to
address thyroid storm indicators cannot be overstated.
Nurses must use keen assessment and critical-thinking
skills to recognize, report, and manage closely the man-
ifestations of this condition. Failure to return balance to
the delicate thyroid feedback cycle can result in loss of
life.

March-April 2017 • Vol. 26/No. 2 145

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