In a thyroid storm presenting in the ED with fever, tachycardia, confusion and elevated thyroid hormones, which immediate treatment is recommended?

• A. Administer intravenous propranolol, propylthiouracil and hydrocortisone
• B. Administer methimazole, propylthiouracil, and hydrocortisone
• C. Administer hydrocortisone only
• D. Administer iodine alone

Answer: (A)

Immediate management of thyroid storm targets rapid control of adrenergic symptoms, inhibition of thyroid hormone production and release, and support of adrenal function. Giving intravenous propranolol quickly blunts tachycardia and other sympathetic effects and also reduces peripheral conversion of T4 to T3. Propylthiouracil is preferred because it blocks new thyroid hormone synthesis and, unlike methimazole alone, also inhibits peripheral conversion, providing a faster overall reduction in active hormone. Hydrocortisone helps prevent potential adrenal insufficiency in the stressed patient and further supports the reduction of T4 to T3 conversion, aiding hemodynamic stabilization. Iodine can be used after thionamide therapy to block release of stored hormone, but it is not sufficient on its own and should follow a thionamide to avoid transient increases in hormone release. This combination—rapid beta-blockade, antithyroid drug with dual action, and glucocorticoid coverage—addresses the key mechanisms driving thyroid storm and is the most effective immediate treatment.