What is the initial treatment sequence for thyroid storm?

• A. Hydrocortisone first, then beta-blocker, then thionamide
• B. Iodine first, then thionamide, then beta-blocker
• C. Beta-blockade, then thionamide, followed by iodine after thionamide, plus hydrocortisone
• D. Thionamide only

Answer: (C)

Thyroid storm requires rapid, layered control of adrenergic symptoms, thyroid hormone synthesis, release, and peripheral conversion. The first step is to blunt the adrenergic overload with a beta-blocker, which quickly reduces heart rate, tremor, and hypertension and lowers myocardial oxygen demand. Next, you shut down new hormone production with a thionamide, which prevents further synthesis of T4 and T3. After that, you give iodine to block release of the preformed thyroid hormones, but only once the thionamide has had a chance to act so iodine isn’t diverted into hormone synthesis. Finally, hydrocortisone is added to treat potential adrenal insufficiency in a crisis and to help decrease peripheral conversion of T4 to the more active T3. This sequence—beta-blocker first, then thionamide, then iodine after thionamide, with hydrocortisone—provides rapid symptomatic control and stabilizes hormone levels effectively.