Thyroid emergencies: thyroid storm and myxoedema crisis

Manage now— do this, in order

• Storm — resuscitate and cool: oxygen, continuous cardiac monitoring and an early 12-lead ECG; rehydrate with 0.9% sodium chloride in measured aliquots of 250–500 mL, reassessing after each, with much greater caution in cardiac failure.
• Storm — antipyresis: tepid sponging and fanning plus paracetamol 1 g orally, by NG tube or per rectum every 6 hours (maximum 4 g daily); children 15 mg/kg per dose 4–6 hourly, maximum 60 mg/kg daily. Salicylates must not be used — aspirin raises the free hormone concentration.
• Storm — β-blockade first, because it works within minutes: propranolol 40–80 mg orally or by NG tube four times daily, or 0.5–2 mg by slow IV bolus repeated with continuous ECG monitoring; esmolol 250–500 micrograms/kg IV then 50–100 micrograms/kg/min where titratability matters; verapamil in asthma. Children: propranolol 0.5–2 mg/kg/day orally divided 6–8 hourly; IV 0.01–0.1 mg/kg over at least 10 minutes (max 1 mg infants, 3 mg older children).Doctor / Nurse
• Storm — thionamide second, always before iodine: propylthiouracil 200–250 mg every 4 hours orally or by NG tube (many load with 500–1000 mg), or carbimazole 20 mg every 6 hours — never delay treatment to obtain propylthiouracil. Children: propylthiouracil 5–10 mg/kg/day divided 4–6 hourly, carbimazole or methimazole 0.5–1 mg/kg/day divided.Doctor / Nurse
• Storm — iodine not less than one hour after the thionamide, then glucocorticoid: saturated potassium iodide or Lugol's solution 0.25 mL every 6 hours orally or by NG tube (lithium carbonate 300 mg every 6–8 hours where iodine is contraindicated, including amiodarone-induced thyrotoxicosis); then hydrocortisone 100 mg IV every 8 hours (300 mg load often used) or dexamethasone 2 mg IV every 6 hours; children hydrocortisone 1–2 mg/kg IV every 6 hours. Take cultures and give broad-spectrum antibiotics for the precipitant. Never give iodine before the thionamide.Doctor / Nurse
• Myxoedema — airway and ventilation first, because this is where these patients die: high-flow oxygen and a blood gas; a rising PaCO₂ with a falling pH in an obtunded hypothermic patient mandates ventilatory support; anticipate a difficult airway. Avoid sedation and opioids — drug handling is grossly impaired and a conventional dose behaves as an overdose.Doctor / NurseNot available at your setup — Arterial blood gas, Mechanical ventilator.
• Myxoedema — glucocorticoid before or with the thyroid hormone, never after: hydrocortisone 100 mg IV bolus, then 200 mg per day (continuous infusion or 50 mg IV every 6 hours); children 1–2 mg/kg IV every 6 hours. Never give levothyroxine before glucocorticoid — it can precipitate adrenal crisis.Doctor / Nurse
• Myxoedema — thyroid hormone before biochemical confirmation: levothyroxine loading 200–400 micrograms, then 1.6 micrograms/kg/day (dose reduced by 25% if IV; use 200 micrograms in the small, frail or elderly and in ischaemic heart disease, with cardiac monitoring). Liothyronine 2.5–10 micrograms every 8 hours may be added; where IV levothyroxine is unavailable, liothyronine 20 micrograms every 8 hours as sole agent, or crush levothyroxine tablets down the NG tube accepting unreliable absorption.Doctor / Nurse
• Myxoedema — supportive measures simultaneously: rewarm slowly and passively (blankets, warm room, warmed fluids and warmed humidified oxygen — aggressive active external rewarming causes hypotension); cautious IV fluids in small measured volumes; correct hyponatraemia by no more than 8–10 mmol/L in 24 hours; correct hypoglycaemia; broad-spectrum antibiotics after cultures, because a normal temperature excludes nothing.