Emergency laparotomy in a patient with thyroid storm, sepsis, and anticoagulation: A hybrid guideline approach to perioperative management

Background: Thyrotoxic crisis is a rare endocrine emergency with mortality rates of 10 to 30%. It can be precipitated by surgical stress and infection. Its diagnosis is particularly treacherous in the emergency surgery setting due to significant symptom overlap with septic shock.Case Presentation: A 45-year-old male with no known thyroid history presented with an acute abdomen. During emergency laparotomy for a perforated diverticulum, he developed progressive, severe tachycardia, hyperthermia (40.1°C), and agitation. Despite aggressive fluid resuscitation and broad-spectrum antibiotics for suspected sepsis, his hemodynamics continued to deteriorate.Management and Outcome: A presumptive diagnosis of thyrotoxic crisis was made. Management was escalated to include intravenous esmolol, oral propylthiouracil, and hydrocortisone. Post-operatively, thyroid function tests confirmed severe hyperthyroidism. The patient was managed in the ICU, with gradual stabilization over 72 hours.Discussion: This case illustrates how the urgency of a surgical emergency can obscure a concurrent endocrine crisis. Thyrotoxic crisis must be a diagnostic consideration in cases of unexplained perioperative instability. Its management includes early recognition, concurrent treatment of the surgical and endocrine emergencies, and essential collaboration between surgical, anesthesia, and intensive care teams.Conclusion: Vigilance for thyrotoxic crisis is essential in the emergency surgical arena. A structured, multidisciplinary approach can prevent diagnostic delay and improve outcomes in this high-mortality condition.