Clinical Considerations Clinical Recognition Almost all cases of thyroid storm occur in patients with known hyperthyroidism, although occasionally, a patient will present initially with thyroid storm Triage Consider thyroid storm in patients with known hyperthyroidism who presents with fever, tachycardia, and systolic hypertension; these patients should receive expedited evaluation and treatment should be initiated quickly Initial Assessment/H&P Most patients will have clinical findings characteristic of hyperthyroidism, including goiter (more than 95%), exophthalmos, tachycardia, bounding pulses, and systolic hypertension Diastolic hypotension, tremulousness, restlessness, mania, delirium, or frankly psychotic behavior may be present A primary feature that distinguishes thyroid storm from uncomplicated hyperthyroidism is the presence of high fever, often as high as 41°C (105.8°F) The marked increase in cardiac workload may result in high-output cardiac failure, in which case hypotension and pulmonary edema may be seen, rather than more classic hypertension Management/Diagnostic Testing Thyroid studies including free thyroxine (T4 ), total and free triiodothyronine (T3 ), and TSH should be obtained urgently to confirm the diagnosis Alternatively, total T4 along with T3 binding resin uptake may be measured if the laboratory cannot measure free levels easily; however, in many cases, therapy must be initiated on the basis of clinical evidence Furthermore, the T4 and T3 values seen in thyroid storm overlap with those found in frank hyperthyroidism without storm Serum electrolytes should be obtained but are unlikely to reveal any characteristic abnormalities, except for evidence of modest dehydration Chest radiograph and ECG are helpful in evaluating and following cardiac status as treatment is initiated Initial treatment is directed toward lowering the metabolic rate and reducing the cardiac workload Subsequent treatment is directed toward controlling thyroid hormone production Because many of the hypermetabolic effects of hyperthyroidism are mediated by the adrenergic system, a β-adrenergic antagonist (propranolol starting at 10 μg/kg intravenously over 10 to 15 minutes, or an esmolol infusion may be initiated with a loading dose of 500 μg/kg/min over minute with maximal infusion doses of 50 to 250 μg/kg/min) is useful in the acute management of thyroid storm Maintenance dosing of propranolol is mg/kg/day divided every hours in neonates and 10 to 40 mg every hours in older children ECG monitoring for heart rate and arrhythmias is recommended Because the metabolic rate is increased about 10% for every degree of body temperature higher than 36.5°C (97.7°F), lowering body temperature is an effective means of reducing the metabolic rate in the patient with thyrotoxicosis Tepid sponging, use of a cooling blanket, and administration of acetaminophen can accomplish this task Aspirin should not be used because