# A nurse cares for a 32-year-old client with Graves disease who develops fever 40 C, HR 156, BP 188/92, agitation, vomiting, and altered mental status 36 hours after thyroidectomy. The nurse identifies thyroid storm. Which interventions should the nurse anticipate? Select all that apply. > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=366307&lang=en > language: en > subject: Medical Emergencies > category: PA ## Question A nurse cares for a 32-year-old client with Graves disease who develops fever 40 C, HR 156, BP 188/92, agitation, vomiting, and altered mental status 36 hours after thyroidectomy. The nurse identifies thyroid storm. Which interventions should the nurse anticipate? Select all that apply. 1 Administer a thionamide (PTU or methimazole) to block thyroid hormone synthesis 2 Administer a beta-blocker such as propranolol IV for adrenergic symptoms 3 Administer iodine solution (SSKI or Lugol) at least 1 hour AFTER the thionamide 4 Initiate active cooling with ice packs and a cooling blanket and treat hyperthermia aggressively 5 Wait for endocrinology consultation before initiating any treatment 6 Administer hydrocortisone for adrenal support and to block peripheral T4 to T3 conversion ## Explanation Thyroid storm is a life-threatening hypermetabolic crisis with mortality 10-25 percent. Treatment is multimodal and time-critical: beta-blocker (propranolol) for adrenergic symptoms, thionamide first to block synthesis, iodine 1 hour AFTER thionamide to block release, glucocorticoid to support adrenal function and reduce T4-to-T3 conversion, and aggressive cooling. Waiting for endocrinology before any treatment is incorrect — initiate per protocol while awaiting consult. ## In-depth explanation Clinical Judgment Thyroid storm precipitants: surgery, infection, trauma, DKA, iodine load, abrupt antithyroid withdrawal. Burch-Wartofsky Point Scale ≥45 = highly suggestive. Treatment order matters: thionamide → 1 hour later iodine → beta-blocker → glucocorticoid → cooling. Iodine BEFORE thionamide can paradoxically increase hormone release. Memory Tip Thyroid storm: 4 Bs — Block synthesis, Block release, Block beta, Block conversion + COOL KR vs U ATA and Korean Endocrine Society both endorse the same multimodal protocol. Burch-Wartofsky scoring widely used in both jurisdictions. ICU monitoring with continuous cardiac monitoring is standard. ## Clinical scenario Clinical Practice Guide ATA thyroid storm bundle (in order): - Beta-blocker: propranolol 60-80 mg PO q4 h or 0.5-1 mg IV q15 min for adrenergic surge - Thionamide: PTU 500-1000 mg PO load then 250 mg q4 h, OR methimazole 60-80 mg PO daily - Iodine: SSKI 5 drops q6 h or Lugol — start at least 1 hour AFTER thionamide - Glucocorticoid: hydrocortisone 100 mg IV q8 h - Cooling: acetaminophen, ice packs, cooling blanket; avoid aspirin (increases free T4) - IV fluids, electrolyte correction, treat precipitating cause Burch-Wartofsky Point Scale (BWPS): - Temperature, CNS, GI, cardiovascular, precipitant - ≥45 highly suggestive; 25-44 impending; <25 unlikely Caution Avoid aspirin and salicylates — they displace thyroid hormone from binding proteins and worsen the storm. Use acetaminophen for fever. Monitor for arrhythmias, heart failure, and rhabdomyolysis from severe hyperthermia. ## Key concepts - **Thyroid storm** — Life-threatening exacerbation of hyperthyroidism with fever, tachycardia, altered mental status, and high-output heart failure. Mortality 10-25 percent. Triggered by surgery, infection, trauma, DKA, iodine load, or abrupt antithyroid withdrawal in clients with Graves disease. - **Thionamide** — Class of antithyroid drugs that block thyroid hormone synthesis. PTU (propylthiouracil) preferred in pregnancy first trimester and thyroid storm because it also blocks peripheral T4-to-T3 conversion. Methimazole preferred long-term due to lower hepatotoxicity. Side effects: rash, agranulocytosis, hepatotoxicity. - **Burch-Wartofsky Point Scale (BWPS)** — Diagnostic clinical score for thyroid storm. Categories: thermoregulation, CNS, GI/hepatic, cardiovascular, congestive heart failure, atrial fibrillation, precipitant history. Score ≥45 highly suggestive of storm; 25-44 impending storm; <25 unlikely. ## Related questions - [A nurse is caring for an alert adult client with type 1 diabetes who reports tremors, swea…](https://mymerci.kr/pages/nclex_q.php?qn_id=360524&lang=en) - [A 58-year-old client arrives at the emergency department with crushing substernal chest pa…](https://mymerci.kr/pages/nclex_q.php?qn_id=362976&lang=en) - [A 72-year-old client is brought to the emergency department by family who report that the …](https://mymerci.kr/pages/nclex_q.php?qn_id=363003&lang=en) - [A 79-year-old client is admitted from a long-term care facility with diarrhea, decreased o…](https://mymerci.kr/pages/nclex_q.php?qn_id=363089&lang=en) - [A 68-year-old client is admitted to the emergency department with suspected sepsis from a …](https://mymerci.kr/pages/nclex_q.php?qn_id=363987&lang=en) - [A nurse is caring for an adult client in the emergency department who is suspected to have…](https://mymerci.kr/pages/nclex_q.php?qn_id=363993&lang=en) - [A nurse is teaching a 72-year-old client with chronic heart failure (reduced ejection frac…](https://mymerci.kr/pages/nclex_q.php?qn_id=366202&lang=en) - [A nurse is caring for an adult client admitted with diabetic ketoacidosis. 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