POTD: Myxedema Coma

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POTD: Myxedema Coma

Clinical Features (Remember LOW and SLOW: low HR, BP, Temp, sugar, RR, Na, Mentation, reflexes):

  • Decreased mental status

  • Hypothermia (<95.9F)

  • Hypotension  

  • Hyponatremia

  • Hypoglycemia  

  • Bradycardia

  • Bradypnea


Work-Up:

  • CMP- looking for hyponatremia, elevated CPK, elevated creatinine, transaminasas

  • CBC- looking for anemia, leukopenia

  • TSH, FT4, FT3- In primary hypothyroidism, TSH will be elevated and T4 and T3 will be low. In secondary hypothyroidism (Pituitary dysfunction) the TSH can be low or normal and T4 and T3 will be low

  • Blood cultures- looking for a secondary sepsis source

  • Cortisol level

  • Lipid panel-  Hyperlipidemia

  • VBG-  looking for hypoglycemia, respiratory acidosis

  • CXR- looking for pleural effusions

  • ECG- looking for bradycardia and rhythm

  • Cardiac POCUS- looking for pericardial effusion


Treatment:

  • Levothyroxine(T4)  100 to 500 mcg IV (Potentially safer in patients with CAD) or

  • Liothyronine (T3) 20mcg IV (Start with 10mcg if elderly or has CAD)

  • Hydrocortisone 100mg IV q8hr

  • Passive rewarming (Do not actively rewarm as rapid peripheral vasodilation may induce worsening hypotension)

  • Mechanical ventilation early may prevent respiratory collapse and severe respiratory acidosis

  • IVFs- dextrose containing fluids for hypoglycemia. If patient is hyponatremic, be cautious of too rapid fluid correction

  • Broad spectrum Antibiotics


Prognosis:

  • Mortality reaches as high as 60%  


Dispo:

  • ICU admission 

Stay well,

TR Adam

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