Which initial management steps are appropriate for thyroid storm?

• A. PTU or methimazole, iodine, beta-blocker, and steroids
• B. Levothyroxine alone
• C. Hydrocortisone only
• D. No antithyroid therapy

Answer: (A)

The essential idea is that thyroid storm requires rapid, multi-pronged therapy that blocks hormone production and release, reduces adrenergic effects, and supports the patient’s stress response. Start with an antithyroid drug (PTU or methimazole) to quickly inhibit new thyroid hormone synthesis. Give iodine after the thionamide to acutely block release of thyroid hormone and help deplete stores. Use a nonselective beta-blocker such as propranolol to control sympathetic symptoms (tachycardia, tremor, agitation) and to decrease peripheral conversion of T4 to T3. Add steroids (like hydrocortisone) to treat potential relative adrenal insufficiency and further reduce conversion of T4 to T3, while supporting hemodynamics. In addition, provide supportive care with IV fluids, cooling, electrolyte management, and treatment of any precipitating illness.

Giving levothyroxine alone would worsen the storm, and using steroids or supportive therapy in isolation would miss the central need to halt hormone synthesis and release and to control adrenergic effects. Without antithyroid therapy, the storm would progress despite other measures.