Thyroid storm — Burch–Wartofsky and the four-pill sequence

Diagnosis is clinical — do not wait for TFTs: no lab abnormality is specific to storm and scoring is clinical. This is thyroid storm: exaggerated hyperthyroidism with fever above 38.5, disproportionate tachycardia, AF, CNS dysfunction and a precipitant (antithyroid withdrawal). BWPS bands are below 25 unlikely, 25-44 impending, 45+ highly suggestive.^[2][17]

Immediate resuscitation:

• Resus bay, monitoring, IV access, oxygen as needed; continuous ECG for AF.
• Cooling plus paracetamol for hyperthermia — aspirin avoided (competes for binding globulin, raising free T4); cautious IV fluids; pregnancy test.
• Treat precipitant aggressively (cultures/antibiotics if infection); ask amiodarone history.
• Send TFTs, FBC, U&E, LFT, glucose, cortisol, cultures, CXR — in parallel with treatment.^[3][17]

Definitive four-pill sequence (order matters):

1. Beta-blockade: propranolol 60-80 mg every 4 hours (or esmolol 0.25-0.5 mg/kg then 0.05-0.1 mg/kg/min IV in ICU; verapamil if beta-blockers unsafe).
2. Block synthesis first: PTU 500-1,000 mg loading, then 250 mg every 4 hours (additional T4-to-T3 block; step down when stable).
3. Block release 1 hour after thionamide: Lugol iodine 8 drops four times a day (or SSKI 5 drops QID) — never before thionamide (extra substrate, Jod-Basedow worsening).
4. Block conversion / cover adrenal: hydrocortisone 100 mg load then 50 mg four times a day.

Disposition: HDU/ICU with endocrinology — guideline-driven care halves day-30 mortality (5.5 vs 10.7%; 50 vs 4.7% if not followed at APACHE 12+).^[10]