it is a potential uncoupler of oxidative phosphorylation that may exacerbate the hypermetabolic state Treatment of the hyperthyroidism in thyroid storm is accomplished by the use of iodide and an inhibitor of iodine oxidation in the thyroid gland such as methimazole 0.5 to 0.7 mg/kg/day divided into three oral doses, which blocks iodine’s ability to combine with tyrosine to form thyroxine and triiodothyronine (T3 ); of note, neither medication inactivates circulating T4 and T3 Propylthiouracil was a first-line agent, but, due to its association with pediatric liver failure, it is now contraindicated in children Iodide rapidly terminates thyroid hormone release; however, this effect is overcome after to days of iodide therapy Iodide also decreases the vascularity of the thyroidal arterial supply and can be particularly useful as a preoperative agent Lugol iodide (or SSKI) to drops once every hours orally or sodium iodide 125 to 250 mg/day intravenously over 24 hours is the usual mode of iodide therapy While iodide can reduce thyroid hormone secretion within 24 hours, methimazole’s effects are minimally useful in acute management because the reduction in thyroid levels may take several days Adequate hydration is essential for effective treatment of thyroid storm The estimate of fluid replacement should include a consideration of the significant increase in fluid requirements caused by fever and an accelerated metabolic rate Glucocorticoids are useful in the acute presentation because they appear to inhibit thyroid hormone release from the thyroid and decrease the peripheral conversion of T4 to T3 Dexamethasone (0.2 mg/kg) or hydrocortisone (5 mg/kg) can be given parenterally during the acute phase Intercurrent infection may be the precipitating factor, thus it should be searched for and treated appropriately Broad-spectrum antibiotics should be considered while awaiting the results of cultures, as there is a known association between thyrotoxicosis and pneumococcal bacteremia Improvement should be seen within a few hours after the initiation of treatment with propranolol, especially in terms of cardiovascular status Clinical Indications for Discharge or Admission All patients in thyroid storm should be admitted Full recovery and adequate control of the underlying thyroid disease take several days to achieve For the patient presenting with thyroid storm, serious consideration should be given to permanent treatment of the hyperthyroidism, either by surgery or radioiodide ablation NEONATAL THYROTOXICOSIS Goals of Treatment The goals of treatment are to control metabolic rate and reduce cardiac workload CLINICAL PEARLS AND PITFALLS