Thyroid Storm and Myxedema

Why this matters

Thyroid storm is a high-thyroid state that the body is not compensating for. It looks like fever, a fast or irregular heart, and agitation or coma, often after an infection, surgery, or a missed medicine. Myxedema coma is the opposite crisis. It looks cold, slow, and altered: low thyroid, hypothermia, a slow heart, and a falling mental status. Both can look like sepsis, overdose, or a primary heart problem.

Hormone replacement and anti-thyroid drugs are hospital treatments. First, protect the airway, check the temperature, and check glucose. Do not use aspirin to treat the fever in suspected storm. Aspirin for chest pain from a possible heart attack is a separate decision. This page has no hormone dose.

Clinical sequence

1. Airway and oxygen if hypoxic. Altered thyroid patients lose their airway. Check glucose in every altered patient.
2. Temperature, a monitor, and a 12-lead. Storm can be atrial fibrillation with a fast rate. Myxedema can be bradycardia and a low-voltage or flat tracing. Treat the unstable rhythm with the usual pathway.
3. For storm, cool as you would for heat illness and give fluids if they are dry and your protocol allows. If an antipyretic is in your scope, use acetaminophen rather than aspirin.
4. For myxedema, remove wet clothes, insulate, and warm the compartment. Aggressive external heat on a profoundly cold, unstable patient can wait on the method your hypothermia protocol already uses. Look at accidental hypothermia.
5. Tell the hospital the thyroid history, the last dose if anyone knows it, and the temperature. Anti-thyroid drugs, iodine, steroids, and IV thyroid hormone are not field orders on this site.

Teaching points

• The 2026 European and American thyroid-emergency consensus, and standard critical-care teaching, say aspirin displaces thyroid hormone from binding proteins. Paracetamol, which is acetaminophen, is the fever medicine they prefer.
• Beta blockers are part of hospital storm care. They are not a dose to invent here, and they are dangerous if this is actually myxedema or decompensated heart failure.
• Infection is a common trigger. Do not skip a sepsis look because the chart says Graves disease.

Common errors

• Do not give aspirin to bring down a thyroid fever.
• Do not put a myxedema patient into a very hot environment without monitoring.
• Do not miss low glucose because the story was “thyroid.”

Practice

Sources & Further Study

Named guidelines for further study. They are not clinical orders and do not replace your protocol or medical direction.

• 2026 joint consensus on thyroid emergencies — supportive care for storm, and aspirin avoided because it can raise free thyroid hormone. Acetaminophen is the antipyretic that guidance prefers. This page publishes no hormone or beta-blocker dose.
• NASEMSO National Model EMS Clinical Guidelines (2022) — endocrine emergencies stay protocol-bound; this site publishes no hormone doses