Medscape is available in 5 Language Editions – Choose your Edition here.


Thyrotoxic Storm Following Thyroidectomy Workup

  • Author: Peter F Czako, MD, FACS; Chief Editor: Arlen D Meyers, MD, MBA  more...
Updated: Jan 21, 2015

Laboratory Studies

Presently, no specific diagnostic criteria to establish the diagnosis of thyroid storm exist.

Burch and Wartofsky have constructed an excellent clinical diagnostic point scale to facilitate a semiquantitative distinction between uncomplicated thyrotoxicosis, impending storm, and established thyroid storm.[4] Laboratory findings in thyroid storm are consistent with those of thyrotoxicosis and include the following:

  • Elevated T 3 and T 4 levels
  • Elevated T 3 uptake
  • Suppressed TSH levels
  • Elevated 24-hour radioiodine uptake

Elevated T4 and decreased TSH are the only abnormal findings needed for conformation of thyrotoxicosis. Treatment should not be withheld for any laboratory confirmation of hyperthyroidism when thyroid storm is suspected clinically. A 2-hour radioiodine uptake is advisable if thyroid storm is suspected and no past history of hyperthyroidism exists.

Other abnormal laboratory values that point toward decompensation of homeostasis include the following:

  • Increased BUN and creatinine kinase
  • Electrolyte imbalance from dehydration, anemia, thrombocytopenia, and leukocytosis
  • Hepatocellular dysfunction as shown by elevated levels of transaminases, lactate dehydrogenase, alkaline phosphatase, and bilirubin
  • Elevated calcium levels
  • Hyperglycemia
Contributor Information and Disclosures

Peter F Czako, MD, FACS Chief, Division of Endocrine Surgery, Medical Director, North Tower Operating Rooms, Surgical Administration, William Beaumont Hospital; Associate Professor, Department of Surgery, Oakland University William Beaumont School of Medicine; Royal Oak Surgical Associates, PC

Peter F Czako, MD, FACS is a member of the following medical societies: American College of Surgeons, American Medical Association, Michigan State Medical Society, American Association of Endocrine Surgeons, Detroit Surgical Society

Disclosure: Nothing to disclose.


Nafisa K Kuwajerwala, MD Staff Surgeon, Breast Care Center, William Beaumont Hospital

Nafisa K Kuwajerwala, MD is a member of the following medical societies: American College of Surgeons, American Society of Breast Surgeons, American Society of Breast Disease

Disclosure: Nothing to disclose.

Gunateet Goswami, MD Consulting Staff, Internal Medicine Associates, Mount Clemens, Michigan; Consulting Staff, Department of Cardiology, Henry Ford Hospital

Gunateet Goswami, MD is a member of the following medical societies: American Medical Association, American Society of Echocardiography, Michigan State Medical Society

Disclosure: Nothing to disclose.

Thabet Abbarah, MD, FACS Consulting Staff, Department of Otolaryngology, North Oakland Medical Centers

Thabet Abbarah, MD, FACS is a member of the following medical societies: American College of Surgeons

Disclosure: Nothing to disclose.

Pankaj Chaturvedi, MBBS, MS, FACS Professor of Head and Neck Surgery, Department of Head and Neck Surgery, Tata Memorial Hospital, India

Pankaj Chaturvedi, MBBS, MS, FACS is a member of the following medical societies: American Association for the Advancement of Science, American Head and Neck Society, Association of Surgeons of India

Disclosure: Nothing to disclose.

Venkata Subramanian Kanthimathinathan, MD Fellow in Bariatric/Advanced Laparoscopic Surgery, University of Missouri Healthcare

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Dean Toriumi, MD Associate Professor, Department of Otolaryngology, University of Illinois Medical Center

Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine

Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan;RxRevu;SymbiaAllergySolutions<br/>Received income in an amount equal to or greater than $250 from: Symbia<br/>Received from Allergy Solutions, Inc for board membership; Received honoraria from RxRevu for chief medical editor; Received salary from Medvoy for founder and president; Received consulting fee from Corvectra for senior medical advisor; Received ownership interest from Cerescan for consulting; Received consulting fee from Essiahealth for advisor; Received consulting fee from Carespan for advisor; Received consulting fee from Covidien for consulting.

Additional Contributors

Mimi S Kokoska, MD Physician, Department of Otolaryngology-Head and Neck Surgery, Aurora Health Care

Mimi S Kokoska, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Association for Physician Leadership, American College of Surgeons, American Head and Neck Society

Disclosure: Nothing to disclose.

  1. Lahey FH. Apathetic thyroidism. Ann Surg. 1931. 93:1026-30.

  2. Akamizu T, Satoh T, Isozaki O, Suzuki A, Wakino S, Iburi T, et al. Diagnostic criteria and clinico-epidemiological features of thyroid storm based on a nationwide survey. Thyroid. 2012 Apr 11. [Medline].

  3. Angell TE, Lechner MG, Nguyen CT, Salvato VL, Nicoloff JT, LoPresti JS. Clinical Features and Hospital Outcomes in Thyroid Storm: A Retrospective Cohort Study. J Clin Endocrinol Metab. 2014 Oct 24. jc20142850. [Medline].

  4. Burch HB, Wartofsky L. Life-threatening thyrotoxicosis. Thyroid storm. Endocrinol Metab Clin North Am. 1993 Jun. 22(2):263-77. [Medline].

  5. Kulaksizoglu M, Gonen MS, Kebapcilar L, Sahin F, Acikgoz B, Demir T, et al. Multiorgan dysfunction accompanied with metimazole and thyroid storm. Transfus Apher Sci. 2012 Apr. 46(2):149-52. [Medline].

  6. Muller C, Perrin P, Faller B, Richter S, Chantrel F. Role of plasma exchange in the thyroid storm. Ther Apher Dial. 2011 Dec. 15(6):522-31. [Medline].

  7. Zhong HJ, Yang TD. Failure of esmolol to control tachycardia associated with thyroid storm after subtotal thyroidectomy. Br J Anaesth. 2012 Sep. 109(3):466-7. [Medline].

  8. Martin D. Disseminated intravascular coagulation precipitated by thyroid storm. South Med J. 2009 Feb. 102(2):193-5. [Medline].

  9. Aulet RM, Wein RO, Siegel RD. Surgical management of an atypical presentation of a thyroid storm. Int J Endocrinol Metab. 2014 Apr. 12(2):e13539. [Medline]. [Full Text].

  10. Brooks MH, Waldstein SS, Bronsky D, Sterling K. Serum triiodothyronine concentration in thyroid storm. J Clin Endocrinol Metab. 1975 Feb. 40(2):339-41. [Medline].

  11. Ecker JL, Musci TJ. Treatment of thyroid disease in pregnancy. Obstet Gynecol Clin North Am. 1997 Sep. 24(3):575-89. [Medline].

  12. Gavin LA. Thyroid crises. Med Clin North Am. 1991 Jan. 75(1):179-93. [Medline].

  13. Ingbar SH. Management of emergencies. IX. Thyrotoxic storm. N Engl J Med. 1966 Jun 2. 274(22):1252-4. [Medline].

  14. Mackin JF, Canary JJ, Pittman CS. Thyroid storm and its management. N Engl J Med. 1974 Dec 26. 291(26):1396-8. [Medline].

  15. Mazzaferri EL, Skillman TG. Thyroid storm. A review of 22 episodes with special emphasis on the use of guanethidine. Arch Intern Med. 1969 Dec. 124(6):684-90. [Medline].

  16. Migneco A, Ojetti V, Testa A. Management of thyrotoxic crisis. Eur Rev Med Pharmacol Sci. 2005 Jan-Feb. 9(1):69-74. [Medline].

  17. Milham S Jr. Scalp defects in infants of mothers treated for hyperthyroidism with methimazole or carbimazole during pregnancy. Teratology. 1985 Oct. 32(2):321. [Medline].

  18. Nakamura S, Nishmyama T, Hanaoka K. [Perioperative thyroid storm in a patient with undiscovered hyperthyroidism]. Masui. 2005 Apr. 54(4):418-9. [Medline].

  19. Prihoda JS, Davis LE. Metabolic emergencies in obstetrics. Obstet Gynecol Clin North Am. 1991 Jun. 18(2):301-18. [Medline].

  20. Rosenberg IN. Thyroid storm. N Engl J Med. 1970 Nov 5. 283(19):1052-3. [Medline].

  21. Scholz GH, Hagemann E, Arkenau C, Engelmann L, Lamesch P, Schreiter D. Is there a place for thyroidectomy in older patients with thyrotoxic storm and cardiorespiratory failure?. Thyroid. 2003 Oct. 13(10):933-40. [Medline].

  22. Tietgens ST, Leinung MC. Thyroid storm. Med Clin North Am. 1995 Jan. 79(1):169-84. [Medline].

  23. Tintillani JE, Kelen GD, Stapazynski JS. Emergency Medicine A Comprehensive Study Guide. 5th ed. McGraw-Hill. 1999:1343-1345.

  24. Utiger RD. The thyroid physiology; hyperthyroidism, hypothyroidism, and the painful thyroid. In: Endocrinology and Metabolism. 2nd ed. New York, NY: McGraw-Hill. 1987:438.

  25. Wing DA, Millar LK, Koonings PP, et al. A comparison of propylthiouracil versus methimazole in the treatment of hyperthyroidism in pregnancy. Am J Obstet Gynecol. 1994 Jan. 170(1 Pt 1):90-5. [Medline].

Pathophysiologic mechanisms of Graves disease relating thyroid-stimulating immunoglobulins to hyperthyroidism and ophthalmopathy. T4 is levothyroxine. T3 is triiodothyronine.
Table. Symptoms and Signs of Thyroid Storm When Compared with Uncomplicated Thyrotoxicosis
Uncomplicated Thyrotoxicosis Thyroid Storm
1. Heat intolerance, diaphoresis 1. Hyperpyrexia, temperature in excess of 106o C, dehydration
2. Sinus tachycardia, heart rate 100-140 2. Heart rate faster than 140 beats/min, hypotension, atrial dysrhythmias, congestive heart failure
3. Diarrhea, increased appetite with loss of weight 3. Nausea, vomiting, severe diarrhea, abdominal pain, hepatocellular dysfunction-jaundice
4. Anxiety, restlessness 4. Confusion, agitation, delirium, frank psychosis, seizures, stupor or coma
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.